MEDICARE: KATRINA KAY BULLARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	68008	CA

General Provider Information

NPI Number	:	1811221823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATRINA KAY BULLARD

Provider Business Mailing Address
First Line	:	4647 ZION AVE
Second Line	:	RM 2145
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-2507
Country	:	US
Telephone Number	:	760-774-0409
Fax Number	:

Provider Business Practice Location Address
First Line	:	37596 COLLEGE DR
Second Line	:	UNIT 101
City	:	PALM DESERT
State	:	CA
Zip	:	92211-2928
Country	:	US
Telephone Number	:	760-774-0409
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2009
Last Update Date	:	12/16/2021

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