Provider Demographics
NPI:1659794436
Name:BULLOCK, BRENT (LPC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 SMITHSON DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-2227
Mailing Address - Country:US
Mailing Address - Phone:757-296-0414
Mailing Address - Fax:
Practice Address - Street 1:4310 INDIAN RIVER RD STE A
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23325-3100
Practice Address - Country:US
Practice Address - Phone:757-296-0414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008190101YP2500X
WALH60712904101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health