Provider Demographics
NPI:1770111668
Name:BULLOCK, SHELBY (SCHOOL PSYCHOLOGY)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:SCHOOL PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3867 SERENITY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6521
Mailing Address - Country:US
Mailing Address - Phone:870-688-8143
Mailing Address - Fax:
Practice Address - Street 1:3867 SERENITY ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-6521
Practice Address - Country:US
Practice Address - Phone:870-688-8143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-28
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool