Basic Information
| Provider Information | |||||||||
| NPI: | 1770612061 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULLARD | ||||||||
| FirstName: | CAREY | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5603 W FRIENDLY AVE # 274B | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274104274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362098147 | ||||||||
| FaxNumber: | 3367409099 | ||||||||
| Practice Location | |||||||||
| Address1: | 5415 W FRIENDLY AVE STE A | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274104255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362098147 | ||||||||
| FaxNumber: | 3367409099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 06/18/2013 | ||||||||
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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 | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 7412896 | 05 | NC | MEDICAID |