Provider Demographics
NPI:1699035808
Name:BULLOCK, NICOLE WRIGHT (LICSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:WRIGHT
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 THURBERS AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4754
Mailing Address - Country:US
Mailing Address - Phone:401-331-1350
Mailing Address - Fax:401-277-3366
Practice Address - Street 1:55 HOPE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2001
Practice Address - Country:US
Practice Address - Phone:401-331-1350
Practice Address - Fax:401-277-3366
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW013571041C0700X
RIISW024801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RICSW01357OtherSTATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DEPARTMENT OF HEALTH
RIISW02480OtherSTATE OF RI