Provider Demographics
NPI:1922794346
Name:BULLARD, MADELYN ELISABETH (AMFT)
Entity Type:Individual
Prefix:
First Name:MADELYN
Middle Name:ELISABETH
Last Name:BULLARD
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 BONITA AVE REAR UNIT
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1923
Mailing Address - Country:US
Mailing Address - Phone:818-321-0537
Mailing Address - Fax:
Practice Address - Street 1:5661 KEITH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1542
Practice Address - Country:US
Practice Address - Phone:510-345-5173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA129337106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist