Provider Demographics
NPI:1679949283
Name:BULLARA, LORIN
Entity type:Individual
Prefix:
First Name:LORIN
Middle Name:
Last Name:BULLARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 METRO PKWY
Mailing Address - Street 2:STE 205
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-9416
Mailing Address - Country:US
Mailing Address - Phone:239-236-8784
Mailing Address - Fax:239-790-2624
Practice Address - Street 1:6507 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-4021
Practice Address - Country:US
Practice Address - Phone:813-374-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW173811041C0700X
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst