=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033044904
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STACY JEBETT BULLARD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2026
-----------------------------------------------------
Last Update Date | 06/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 291 WALL ST STE 3
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12401-3849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-521-3975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42 POST ST
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12401-6048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-740-9201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------