Provider Demographics
NPI:1609005446
Name:BULLOCK, MICHAEL CRAIG (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CRAIG
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 15TH ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2608
Mailing Address - Country:US
Mailing Address - Phone:706-733-0188
Mailing Address - Fax:
Practice Address - Street 1:950 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2608
Practice Address - Country:US
Practice Address - Phone:706-733-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0055751041C0700X
SC111961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9123OtherN/A