Provider Demographics
NPI:1093370314
Name:BULLARA, DANIEL THOMAS (PHD, BCBA, LBA)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:THOMAS
Last Name:BULLARA
Suffix:
Gender:M
Credentials:PHD, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4515
Mailing Address - Country:US
Mailing Address - Phone:530-598-2754
Mailing Address - Fax:
Practice Address - Street 1:601 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:530-598-2754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018045058103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst