Provider Demographics
NPI:1558825141
Name:BULLOCK, TRACY (LMSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 OAKWOOD DR STE 112
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-6206
Mailing Address - Country:US
Mailing Address - Phone:248-505-6133
Mailing Address - Fax:
Practice Address - Street 1:805 OAKWOOD DR STE 112
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-6206
Practice Address - Country:US
Practice Address - Phone:248-505-6133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010691581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical