Provider Demographics
NPI:1609988724
Name:BULLARD, LAUREN (MA)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:
Last Name:BULLARD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:314 N. CEDAR STREET
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62565
Mailing Address - Country:US
Mailing Address - Phone:217-774-2113
Mailing Address - Fax:217-774-2256
Practice Address - Street 1:1300 CHARLESTON AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4016
Practice Address - Country:US
Practice Address - Phone:217-234-6405
Practice Address - Fax:217-258-6136
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-000972101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional