Provider Demographics
NPI:1972201747
Name:BULLARD, CYNTHIA D (LAC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:D
Last Name:BULLARD
Suffix:
Gender:F
Credentials:LAC
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 1251
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-1251
Mailing Address - Country:US
Mailing Address - Phone:870-489-5454
Mailing Address - Fax:
Practice Address - Street 1:7958 HIGHWAY 79 S
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-4541
Practice Address - Country:US
Practice Address - Phone:870-489-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2302010101YM0800X
AR112061225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor