Provider Demographics
NPI:1366501389
Name:BULLOCK, SUSAN (LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:LAHEY CLINIC
Mailing Address - Street 2:41 MALL RD.
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8806
Mailing Address - Fax:781-744-5235
Practice Address - Street 1:LAHEY CLINIC
Practice Address - Street 2:41 MALL RD.
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8806
Practice Address - Fax:781-744-5235
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2132311041C0700X
MA1145661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA001312802Medicare PIN
MA001312803Medicare PIN