Provider Demographics
NPI:1376624791
Name:TULLOCH, EDWIN FRED (PHD LPC LMFT)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:FRED
Last Name:TULLOCH
Suffix:
Gender:M
Credentials:PHD LPC LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3908 DANZIG DR
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052
Mailing Address - Country:US
Mailing Address - Phone:972-617-0242
Mailing Address - Fax:254-687-2727
Practice Address - Street 1:543 E FREEMAN
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116
Practice Address - Country:US
Practice Address - Phone:972-617-0242
Practice Address - Fax:254-637-2727
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9172101YP2500X
TX773106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist