Provider Demographics
NPI:1184894552
Name:BULLARD, INGRID VANESSA (SLP-CCC)
Entity type:Individual
Prefix:MRS
First Name:INGRID
Middle Name:VANESSA
Last Name:BULLARD
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4354 TOKOSE PL
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811-1430
Mailing Address - Country:US
Mailing Address - Phone:813-416-7148
Mailing Address - Fax:
Practice Address - Street 1:4354 TOKOSE PL
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-1430
Practice Address - Country:US
Practice Address - Phone:813-416-7148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8474235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist