Provider Demographics
NPI:1457526337
Name:BULLOCH, MATT KEVIN (LPC NCC)
Entity Type:Individual
Prefix:MR
First Name:MATT
Middle Name:KEVIN
Last Name:BULLOCH
Suffix:
Gender:M
Credentials:LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 IRONWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-5125
Mailing Address - Country:US
Mailing Address - Phone:435-327-2137
Mailing Address - Fax:
Practice Address - Street 1:2460 W HIGHWAY 56
Practice Address - Street 2:#5
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-4118
Practice Address - Country:US
Practice Address - Phone:435-327-2137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2785863-6004101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health