Provider Demographics
NPI:1760670962
Name:BULLOCK, EMILY YOUNG (PSYD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:YOUNG
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N EAST PROMONTORY STE 200
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2950
Mailing Address - Country:US
Mailing Address - Phone:801-844-1615
Mailing Address - Fax:844-221-4750
Practice Address - Street 1:240 N EAST PROMONTORY STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2950
Practice Address - Country:US
Practice Address - Phone:801-844-1615
Practice Address - Fax:844-221-4750
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7510289-2501OtherLICENSED PSYCHOLOGIST