Provider Demographics
NPI:1326288507
Name:BULLOCK, SCOTT K (MSW, LISW)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:K
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 933421
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-5072
Mailing Address - Fax:937-641-6129
Practice Address - Street 1:700 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-1303
Practice Address - Country:US
Practice Address - Phone:937-641-4040
Practice Address - Fax:937-641-3066
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-27
Last Update Date:2023-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 0008810-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0002716Medicaid