Provider Demographics
NPI:1932374766
Name:BULLOCK, RODERICK CONLEY
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:CONLEY
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3104 MINTLEAF DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-3069
Mailing Address - Country:US
Mailing Address - Phone:704-589-1478
Mailing Address - Fax:
Practice Address - Street 1:3104 MINTLEAF DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269
Practice Address - Country:US
Practice Address - Phone:704-519-8264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)