Provider Demographics
NPI:1023381613
Name:BULLOCK, THERESA ALICE (MSW)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ALICE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 N ORIENTAL ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3559
Mailing Address - Country:US
Mailing Address - Phone:336-414-2508
Mailing Address - Fax:
Practice Address - Street 1:526 N ORIENTAL ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3559
Practice Address - Country:US
Practice Address - Phone:336-414-2508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008388A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1023381613Medicaid
NC1023381613Medicaid