Basic Information
| Provider Information | |||||||||
| NPI: | 1447346770 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLARD | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, P-LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107153371 | ||||||||
| FaxNumber: | 9107155391 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107153371 | ||||||||
| FaxNumber: | 9107155391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 09/25/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | P003261 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | C005731 | 01 | NC | NC LICENSE - LCSW | OTHER |