Provider Demographics
NPI:1417131814
Name:BULLARD, SUSAN H (LMSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:H
Last Name:BULLARD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29716-0746
Mailing Address - Country:US
Mailing Address - Phone:803-579-1559
Mailing Address - Fax:
Practice Address - Street 1:125 FORREST ST
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-2341
Practice Address - Country:US
Practice Address - Phone:803-579-1559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8752104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
570629234OtherTAX ID
570629234OtherTAX ID
SCQ347443859Medicare PIN