Provider Demographics
NPI:1114320587
Name:BULLOCK, ASHLEY BROWN
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:BROWN
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 1:1735 YORK AVE
Mailing Address - Street 2:APT 9F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-6855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:276 5TH AVE
Practice Address - Street 2:SUITE 307B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-4509
Practice Address - Country:US
Practice Address - Phone:347-218-1289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY68 020490103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical