Provider Demographics
NPI:1003043696
Name:BULLOCK, CHESTER WAYNE JR (PSYD, MED)
Entity Type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:WAYNE
Last Name:BULLOCK
Suffix:JR
Gender:M
Credentials:PSYD, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 17TH ST NW STE 419
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20006-2605
Mailing Address - Country:US
Mailing Address - Phone:202-505-2795
Mailing Address - Fax:
Practice Address - Street 1:910 17TH ST NW STE 419
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-2605
Practice Address - Country:US
Practice Address - Phone:202-505-2795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist