Provider Demographics
NPI:1376609594
Name:BULLARD, MARTHA (MSW, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:
Last Name:BULLARD
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 WILLAGILLESPIE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-6721
Mailing Address - Country:US
Mailing Address - Phone:541-343-7171
Mailing Address - Fax:541-284-1765
Practice Address - Street 1:1045 WILLAGILLESPIE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6721
Practice Address - Country:US
Practice Address - Phone:541-343-7171
Practice Address - Fax:541-284-1765
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL25041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1261479-9OtherBIN
20-2743028OtherEIN
20-2743028OtherEIN