Provider Demographics
NPI:1265072326
Name:BULLARD, RYAN (LCSW, BCD, PMH-C)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:BULLARD
Suffix:
Gender:M
Credentials:LCSW, BCD, PMH-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 JOHN KING RD STE 18
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5731
Mailing Address - Country:US
Mailing Address - Phone:850-347-5457
Mailing Address - Fax:850-779-3117
Practice Address - Street 1:128 JOHN KING RD STE 18
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5731
Practice Address - Country:US
Practice Address - Phone:850-347-5457
Practice Address - Fax:850-779-3117
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YA0400X
101YM0800X
SW169481041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool