Provider Demographics
NPI:1902189806
Name:BULLOCK, KYLE (LCSW)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N WABASH AVE UNIT 1207
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-5656
Mailing Address - Country:US
Mailing Address - Phone:562-400-3838
Mailing Address - Fax:
Practice Address - Street 1:405 N WABASH AVE UNIT 1207
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5656
Practice Address - Country:US
Practice Address - Phone:562-400-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0220141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical