Healthcare Provider Details

I. General information

NPI: 1447770714
Provider Name (Legal Business Name): SHAMEKA BULLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 06/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10603 DOWNEY AVE
DOWNEY CA
90241-3426
US

IV. Provider business mailing address

750 GAVIOTA AVE APT 7
LONG BEACH CA
90813-6340
US

V. Phone/Fax

Practice location:
  • Phone: 562-622-2268
  • Fax:
Mailing address:
  • Phone: 562-215-3330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC035650915
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: