Basic Information
| Provider Information | |||||||||
| NPI: | 1861870149 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULLARD | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 COMMERCE PLAZA CIR | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283727386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105212900 | ||||||||
| FaxNumber: | 9107759165 | ||||||||
| Practice Location | |||||||||
| Address1: | 1309 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283586031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107391666 | ||||||||
| FaxNumber: | 9107396822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2015 | ||||||||
| LastUpdateDate: | 10/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 20975 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1861870149 | 05 | NC | MEDICAID |