Healthcare Provider Details

I. General information

NPI: 1679949283
Provider Name (Legal Business Name): LORIN BULLARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6507 GUNN HWY
TAMPA FL
33625-4021
US

IV. Provider business mailing address

4310 METRO PKWY STE 205
FORT MYERS FL
33916-9416
US

V. Phone/Fax

Practice location:
  • Phone: 813-374-2070
  • Fax:
Mailing address:
  • Phone: 239-236-8784
  • Fax: 239-790-2624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW17381
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: