Provider Demographics
NPI:1861753121
Name:BULLOCK, DENISE (MSED)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 LILLIAN DR
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10977-6504
Mailing Address - Country:US
Mailing Address - Phone:917-498-1640
Mailing Address - Fax:
Practice Address - Street 1:17 LILLIAN DR
Practice Address - Street 2:
Practice Address - City:CHESTNUT RIDGE
Practice Address - State:NY
Practice Address - Zip Code:10977-6504
Practice Address - Country:US
Practice Address - Phone:917-498-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17400000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist