Healthcare Provider Details

I. General information

NPI: 1346642956
Provider Name (Legal Business Name): MELISSA BULLARD PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 SW OAK ST STE 500
TIGARD OR
97223-6597
US

IV. Provider business mailing address

9600 SW OAK ST STE 500
TIGARD OR
97223-6597
US

V. Phone/Fax

Practice location:
  • Phone: 971-364-8069
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23-QMHP-R-2380
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3872
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: