Provider Demographics
NPI:1770188997
Name:BULLOCK, SHARLENE TERESA (LMHC)
Entity Type:Individual
Prefix:
First Name:SHARLENE
Middle Name:TERESA
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 1:51 SPENCER ST APT 2
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-1909
Mailing Address - Country:US
Mailing Address - Phone:857-654-8501
Mailing Address - Fax:
Practice Address - Street 1:51 SPENCER ST APT 2
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-1909
Practice Address - Country:US
Practice Address - Phone:857-654-8501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8297101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty