Provider Demographics
NPI:1033550934
Name:BULLARD, KATHLEEN M (MS, LPC-IT, SAC-IT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:BULLARD
Suffix:
Gender:F
Credentials:MS, LPC-IT, SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 W MAIN ST STE 900
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-1985
Mailing Address - Country:US
Mailing Address - Phone:262-806-1467
Mailing Address - Fax:262-661-7702
Practice Address - Street 1:4003 80TH ST STE 101
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-4995
Practice Address - Country:US
Practice Address - Phone:262-806-1467
Practice Address - Fax:262-661-7702
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1680-130101YA0400X
WI6363-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1033550934Medicaid
WI1063993038Medicaid