Healthcare Provider Details

I. General information

NPI: 1518568732
Provider Name (Legal Business Name): JUSTIN BULLARD PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 GALVIN RD N
BELLEVUE NE
68005-4852
US

IV. Provider business mailing address

7318 E PINE ST
TULSA OK
74115-5743
US

V. Phone/Fax

Practice location:
  • Phone: 918-880-6896
  • Fax:
Mailing address:
  • Phone: 918-880-6896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1405
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1018
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: