Provider Demographics
NPI:1275714032
Name:BULLOCK, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
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 1:41 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-3796
Mailing Address - Country:US
Mailing Address - Phone:860-454-0279
Mailing Address - Fax:
Practice Address - Street 1:70 S WATER ST
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06088-6600
Practice Address - Country:US
Practice Address - Phone:860-623-3039
Practice Address - Fax:860-292-1518
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health