Provider Demographics
NPI:1902522675
Name:BULLOCK, MICHELE (LSW)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 CAVANAUGH DRIVE, COMMERCIAL POINT, OH, USA
Mailing Address - Street 2:
Mailing Address - City:COMMERCIAL POINT
Mailing Address - State:OH
Mailing Address - Zip Code:43116
Mailing Address - Country:US
Mailing Address - Phone:614-561-4595
Mailing Address - Fax:
Practice Address - Street 1:209 CAVANAUGH DRIVE, COMMERCIAL POINT, OH, USA
Practice Address - Street 2:
Practice Address - City:COMMERCIAL POINT
Practice Address - State:OH
Practice Address - Zip Code:43116
Practice Address - Country:US
Practice Address - Phone:614-561-4595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0025537104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker