Provider Demographics
NPI:1225442049
Name:CAREY-BULLARD, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CAREY-BULLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 PORTABELLA TRL
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-4006
Mailing Address - Country:US
Mailing Address - Phone:989-772-2967
Mailing Address - Fax:989-772-9454
Practice Address - Street 1:1524 PORTABELLA TRL
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-4006
Practice Address - Country:US
Practice Address - Phone:989-772-2967
Practice Address - Fax:989-772-9454
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002865225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235490Medicaid