Provider Demographics
NPI:1245954445
Name:BULLOCK, ALYSON (AMFT)
Entity type:Individual
Prefix:
First Name:ALYSON
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-3331
Mailing Address - Country:US
Mailing Address - Phone:858-349-0300
Mailing Address - Fax:
Practice Address - Street 1:71 CARROLL ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-3331
Practice Address - Country:US
Practice Address - Phone:858-349-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty