Provider Demographics
NPI:1649304452
Name:BULLOCK, WESLEY ALLEN (PHD)
Entity type:Individual
Prefix:PROF
First Name:WESLEY
Middle Name:ALLEN
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 W BANCROFT ST
Mailing Address - Street 2:UNIVERSITY OF TOLEDO, DEPT. OF PSYCHOLOGY # 948
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3328
Mailing Address - Country:US
Mailing Address - Phone:419-530-2721
Mailing Address - Fax:419-530-8479
Practice Address - Street 1:2801 W BANCROFT ST
Practice Address - Street 2:UNIVERSITY OF TOLEDO, DEPT. OF PSYCHOLOGY # 948
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3328
Practice Address - Country:US
Practice Address - Phone:419-530-2721
Practice Address - Fax:419-530-8479
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3856103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical