Provider Demographics
NPI:1376315754
Name:BULLOCK, REGINA MARIE
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 ADELINE ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-2408
Mailing Address - Country:US
Mailing Address - Phone:510-421-4804
Mailing Address - Fax:
Practice Address - Street 1:2730 ADELINE ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2408
Practice Address - Country:US
Practice Address - Phone:510-421-4804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-27
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health