Provider Demographics
NPI:1265708564
Name:BULLOCK, KIMBERLY ANTOINETTE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANTOINETTE
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 1:17657 132ND AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-5839
Mailing Address - Country:US
Mailing Address - Phone:718-712-1790
Mailing Address - Fax:516-292-7008
Practice Address - Street 1:17657 132ND AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-5839
Practice Address - Country:US
Practice Address - Phone:718-712-1790
Practice Address - Fax:516-292-7008
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0753921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical