Provider Demographics
NPI:1093451726
Name:BULLOCK, LESLIE NICOLE
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:NICOLE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 CYPRESS CREEK LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-1521
Mailing Address - Country:US
Mailing Address - Phone:325-201-3855
Mailing Address - Fax:
Practice Address - Street 1:325 CYPRESS CREEK LN
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-1521
Practice Address - Country:US
Practice Address - Phone:325-201-3855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35015103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty