Provider Demographics
NPI:1346868783
Name:BULLOCK, WALTER J (MS)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:J
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 WAKELING ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2855
Mailing Address - Country:US
Mailing Address - Phone:267-403-7906
Mailing Address - Fax:
Practice Address - Street 1:1831 WAKELING ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2855
Practice Address - Country:US
Practice Address - Phone:267-403-7906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty