Provider Demographics
NPI:1104832815
Name:BULLOCK, JAMES HOWARD (PSYD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:HOWARD
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9097 ATLEE STATION RD
Mailing Address - Street 2:SUITE 219
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2525
Mailing Address - Country:US
Mailing Address - Phone:804-730-2829
Mailing Address - Fax:804-730-2829
Practice Address - Street 1:9097 ATLEE STATION RD
Practice Address - Street 2:SUITE 219
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2525
Practice Address - Country:US
Practice Address - Phone:804-730-2829
Practice Address - Fax:804-730-2829
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001604103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7705077Medicaid
VA440242OtherANTHEM
VAR36744Medicare UPIN