Provider Demographics
NPI:1851989628
Name:BULLOCKS, CARNESHA MISHELL
Entity Type:Individual
Prefix:
First Name:CARNESHA
Middle Name:MISHELL
Last Name:BULLOCKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 IRIS TRL
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-7543
Mailing Address - Country:US
Mailing Address - Phone:909-328-0985
Mailing Address - Fax:
Practice Address - Street 1:1215 IRIS TRL
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-7543
Practice Address - Country:US
Practice Address - Phone:909-328-0985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94025611103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical