Provider Demographics
NPI:1851435721
Name:BULLARD, MELISSA ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ANN
Last Name:BULLARD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:697 HANNAH AVE STE D
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3399
Mailing Address - Country:US
Mailing Address - Phone:231-392-3611
Mailing Address - Fax:844-213-1595
Practice Address - Street 1:697 HANNAH AVE STE D
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3399
Practice Address - Country:US
Practice Address - Phone:231-392-3611
Practice Address - Fax:844-213-1595
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012645103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680B812170OtherBCBSM
MI680B812170OtherBCBSM