Basic Information
| Provider Information | |||||||||
| NPI: | 1790872513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PULLEN | ||||||||
| FirstName: | CONSTANCE | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 25800 AVONIA LN | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216621417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108226501 | ||||||||
| FaxNumber: | 4103346960 | ||||||||
| Practice Location | |||||||||
| Address1: | 25800 AVONIA LN | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216621417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108226501 | ||||||||
| FaxNumber: | 4103346960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 06299 | MD | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 06299 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6293528 | 01 | UNITED BEHAVIOR HEALTH | OTHER | 0007 | 01 | DC | CAREFIRST FEDERAL PIN | OTHER | 259147000 | 01 | MD | MAGELLAN | OTHER | 352441000 | 01 | MD | MAGELLAN PIN | OTHER | 100067559001 | 01 | AMERICAN PSYCH SYSTEM | OTHER | 52742702 | 01 | MD | CAREFIRST BCBS PIN | OTHER | LM49EA | 01 | MD | CAREFIRST BCBS | OTHER | 2101679 | 01 | UNITEDHEALTHCARE MAMSI PI | OTHER | 609550002 | 05 | MD | MEDICAID | 609550005 | 05 | MD | MEDICAID | 517251 | 01 | UHC MAMSI GROUP | OTHER | 723622 | 01 | NCPPO PIN | OTHER | R968 | 01 | DC | CAREFIRST FEDERAL GROUP | OTHER |