Provider Demographics
NPI:1811490147
Name:BULLOCK, NIKELLE SHARISSE (ED S)
Entity type:Individual
Prefix:MRS
First Name:NIKELLE
Middle Name:SHARISSE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:ED S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-3568
Mailing Address - Country:US
Mailing Address - Phone:757-727-2450
Mailing Address - Fax:757-727-2464
Practice Address - Street 1:1 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-3568
Practice Address - Country:US
Practice Address - Phone:757-727-2450
Practice Address - Fax:757-727-2464
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0813000541103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool