Provider Demographics
NPI:1437553989
Name:BULLOCK, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
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 1:7437 COBBLESTONE EAST DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-9108
Mailing Address - Country:US
Mailing Address - Phone:317-418-7840
Mailing Address - Fax:
Practice Address - Street 1:7437 COBBLESTONE EAST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-9108
Practice Address - Country:US
Practice Address - Phone:317-418-7840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN611-1915(I) CMHWMedicaid
IN11 MENTAL HEALTHMedicaid