Provider Demographics
NPI:1639595515
Name:BULLOCK, ALEX
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2938 DAYBREAKER DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5855
Mailing Address - Country:US
Mailing Address - Phone:435-659-1262
Mailing Address - Fax:
Practice Address - Street 1:5500 W BAGLEY PARK RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84081-5697
Practice Address - Country:US
Practice Address - Phone:801-282-4315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst