1417131814 NPI number — MS. SUSAN H BULLARD LMSW

Table of content: STEPHANIE CANELO (NPI 1598290413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417131814 NPI number — MS. SUSAN H BULLARD LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BULLARD
Provider First Name:
SUSAN
Provider Middle Name:
H
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417131814
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 746
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MILL
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29716-0746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-579-1559
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 FORREST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29715-2341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-579-1559
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  8752 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 570629234 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".




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