Provider Demographics
NPI:1407057615
Name:UNIVERSITY OF TOLEDO PSYCHOLOGY CLINIC
Entity Type:Organization
Organization Name:UNIVERSITY OF TOLEDO PSYCHOLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:419-530-2721
Mailing Address - Street 1:2801 W BANCROFT ST
Mailing Address - Street 2:DEPT. OF PSYCHOLOGY (MS # 948), UNIVERSITY OF TOLEDO
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3328
Mailing Address - Country:US
Mailing Address - Phone:419-530-2721
Mailing Address - Fax:419-530-8479
Practice Address - Street 1:2801 W BANCROFT ST
Practice Address - Street 2:DEPT. OF PSYCHOLOGY (MS # 948), UNIVERSITY OF TOLEDO
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3328
Practice Address - Country:US
Practice Address - Phone:419-530-2721
Practice Address - Fax:419-530-8479
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF TOLEDO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-29
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3856251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health