Provider Demographics
NPI:1023595766
Name:BULLOCK, NICOLE ELIZABETH (LCSW)
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 BRET AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-5103
Mailing Address - Country:US
Mailing Address - Phone:707-339-2326
Mailing Address - Fax:
Practice Address - Street 1:1350 S ELISEO DR STE 130
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2011
Practice Address - Country:US
Practice Address - Phone:415-847-1124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW716191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical