Provider Demographics
NPI:1548616097
Name:BULLOCK, LENA VAUGHN (BCBA)
Entity Type:Individual
Prefix:
First Name:LENA
Middle Name:VAUGHN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2580 LIN DO CT
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-1832
Mailing Address - Country:US
Mailing Address - Phone:803-905-4427
Mailing Address - Fax:803-905-4431
Practice Address - Street 1:444 2ND LOOP RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505
Practice Address - Country:US
Practice Address - Phone:843-536-8674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst