Provider Demographics
NPI:1043908759
Name:BULLOCK, RENEE MONIQUE (PSYD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:MONIQUE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 TYLER CIR APT 132
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-1126
Mailing Address - Country:US
Mailing Address - Phone:804-246-3033
Mailing Address - Fax:
Practice Address - Street 1:9720 CAPITAL CT STE 303
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-2051
Practice Address - Country:US
Practice Address - Phone:703-881-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704015690101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health