Provider Demographics
NPI:1154137412
Name:POULLARD, ALFRED CHARLES
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:CHARLES
Last Name:POULLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5445 SPENCER DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77708-5027
Mailing Address - Country:US
Mailing Address - Phone:409-201-4706
Mailing Address - Fax:
Practice Address - Street 1:6642 PHELAN BLVD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-5966
Practice Address - Country:US
Practice Address - Phone:409-242-1529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty