Provider Demographics
NPI:1811221823
Name:BULLARD, KATRINA KAY
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:KAY
Last Name: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 1:4647 ZION AVE
Mailing Address - Street 2:RM 2145
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2507
Mailing Address - Country:US
Mailing Address - Phone:760-774-0409
Mailing Address - Fax:
Practice Address - Street 1:37596 COLLEGE DR
Practice Address - Street 2:UNIT 101
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-2928
Practice Address - Country:US
Practice Address - Phone:760-774-0409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA680081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical