MEDICARE: KAYLA GENTRY BULLARD MSW, LCSWA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	P016296	NC

General Provider Information

NPI Number	:	1255909594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA GENTRY BULLARD MSW, LCSWA

Provider Business Mailing Address
First Line	:	111 SYLVAN RD
Second Line	:
City	:	THURMOND
State	:	NC
Zip	:	28683-9439
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	714 CAROLINA AVE STE A
Second Line	:
City	:	YADKINVILLE
State	:	NC
Zip	:	27055-7793
Country	:	US
Telephone Number	:	336-818-0733
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2021
Last Update Date	:	01/20/2022

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