Healthcare Provider Details

I. General information

NPI: 1033044904
Provider Name (Legal Business Name): STACY JEBETT BULLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 WALL ST STE 3
KINGSTON NY
12401-3849
US

IV. Provider business mailing address

42 POST ST
KINGSTON NY
12401-6048
US

V. Phone/Fax

Practice location:
  • Phone: 914-521-3975
  • Fax:
Mailing address:
  • Phone: 917-740-9201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: