Healthcare Provider Details

I. General information

NPI: 1447346770
Provider Name (Legal Business Name): AMANDA MARIE BULLARD MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MEMORIAL DR
PINEHURST NC
28374-8708
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE
FORT LIBERTY NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-715-3371
  • Fax: 910-715-5391
Mailing address:
  • Phone: 910-907-8922
  • Fax: 910-907-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC005731
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierC005731
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerNC LICENSE - LCSW

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: