Provider Demographics
NPI:1912674896
Name:BULLOCK, VIRGINIA (MA, LCMHCA, NCC)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MA, LCMHCA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 N ELM ST APT 3M
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2868
Mailing Address - Country:US
Mailing Address - Phone:205-876-4665
Mailing Address - Fax:
Practice Address - Street 1:1205 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5762
Practice Address - Country:US
Practice Address - Phone:336-663-3107
Practice Address - Fax:336-792-1029
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16909101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty