Provider Demographics
NPI:1366003238
Name:BULLOCK, SHAYLA LATEEFAH (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:SHAYLA
Middle Name:LATEEFAH
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MISS
Other - First Name:SHAYLA
Other - Middle Name:L
Other - Last Name:DUNCAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14114 OXFORD DR
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5851
Mailing Address - Country:US
Mailing Address - Phone:301-256-8548
Mailing Address - Fax:
Practice Address - Street 1:4421 FORBES BLVD STE F
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4384
Practice Address - Country:US
Practice Address - Phone:301-256-8548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4067101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional