Provider Demographics
NPI:1629315288
Name:BULLOCK, MONICA MICHELLE (LCPC)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:MICHELLE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7712 KNOTTY PINE CT
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-2912
Mailing Address - Country:US
Mailing Address - Phone:773-307-5023
Mailing Address - Fax:
Practice Address - Street 1:7712 KNOTTY PINE CT
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-2912
Practice Address - Country:US
Practice Address - Phone:773-307-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-15
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009519101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.009519OtherLCPC