Provider Demographics
NPI:1427304898
Name:BULLARD, TY ALLISON (MED)
Entity type:Individual
Prefix:MS
First Name:TY
Middle Name:ALLISON
Last Name:BULLARD
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MRS
Other - First Name:TY
Other - Middle Name:BULLARD
Other - Last Name:WERTHEIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:505 W MAIN ST STE 225
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-5703
Mailing Address - Country:US
Mailing Address - Phone:065-894-6644
Mailing Address - Fax:844-837-1209
Practice Address - Street 1:505 W MAIN ST STE 225
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-5703
Practice Address - Country:US
Practice Address - Phone:406-589-4664
Practice Address - Fax:844-837-1209
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2020-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT7174089Medicaid