Provider Demographics
NPI:1326189457
Name:BULLOCK, LYDIA DAVIDSON (LCSW)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:DAVIDSON
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5110
Mailing Address - Country:US
Mailing Address - Phone:801-475-4609
Mailing Address - Fax:
Practice Address - Street 1:2416 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5110
Practice Address - Country:US
Practice Address - Phone:801-475-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5297671-35011041C0700X
UT5297671-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical