Provider Demographics
NPI:1376682161
Name:BULLOCK, MICHELE LYNN (NCC, LPC)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYNN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 S HIGHLAND ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-1826
Mailing Address - Country:US
Mailing Address - Phone:860-258-4171
Mailing Address - Fax:203-287-8292
Practice Address - Street 1:57 PLAINS RD STE 2B
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06461-2573
Practice Address - Country:US
Practice Address - Phone:203-794-6992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001538101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health