Provider Demographics
NPI:1922786268
Name:BULLOCK, IRENE ERVIN (LCSW)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:ERVIN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:ELIZABETH
Other - Last Name:ERVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:7331 RIVENDELL TER
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-5970
Mailing Address - Country:US
Mailing Address - Phone:804-497-9518
Mailing Address - Fax:
Practice Address - Street 1:1600 WESTBROOK AVE STE 134
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-3326
Practice Address - Country:US
Practice Address - Phone:804-292-3500
Practice Address - Fax:888-382-0230
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040149001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty