Provider Demographics
NPI:1265948038
Name:BULLOCK, TRACEY LA DAWN (RBT)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LA DAWN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6708
Mailing Address - Country:US
Mailing Address - Phone:575-825-1229
Mailing Address - Fax:
Practice Address - Street 1:830 W 14TH ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6708
Practice Address - Country:US
Practice Address - Phone:575-825-1229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRBT-16-22817106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMRBT-16-22817Medicaid