Provider Demographics
NPI:1659794436
Name:BULLOCK, BRENT (LPC)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 BATTLEFIELD BLVD S UNIT 15777
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23328-1231
Mailing Address - Country:US
Mailing Address - Phone:757-296-0414
Mailing Address - Fax:
Practice Address - Street 1:1100 BATTLEFIELD BLVD S UNIT 15777
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23328-1231
Practice Address - Country:US
Practice Address - Phone:757-296-0414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60712904101YM0800X
VA0701008190101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health