Provider Demographics
NPI:1710245758
Name:BULLOCK, GIZELLE MARIE (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:GIZELLE
Middle Name:MARIE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 LISBON ST
Mailing Address - Street 2:
Mailing Address - City:HEUVELTON
Mailing Address - State:NY
Mailing Address - Zip Code:13654-3130
Mailing Address - Country:US
Mailing Address - Phone:315-244-0244
Mailing Address - Fax:315-254-2811
Practice Address - Street 1:76 LISBON ST
Practice Address - Street 2:
Practice Address - City:HEUVELTON
Practice Address - State:NY
Practice Address - Zip Code:13654-3130
Practice Address - Country:US
Practice Address - Phone:315-244-0244
Practice Address - Fax:315-254-2811
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-27
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004799101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health