Healthcare Provider Details

I. General information

NPI: 1174446124
Provider Name (Legal Business Name): RACHEL LYNN BULLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47818 VAN DYKE AVE
SHELBY TOWNSHIP MI
48317-3373
US

IV. Provider business mailing address

2222 W GRAND RIVER AVE STE A
OKEMOS MI
48864-1604
US

V. Phone/Fax

Practice location:
  • Phone: 586-323-3620
  • Fax:
Mailing address:
  • Phone: 248-247-2033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6361007662
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: