Provider Demographics
NPI:1871897108
Name:BULLOCK, TAKIA L (MSW)
Entity type:Individual
Prefix:MS
First Name:TAKIA
Middle Name:L
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4040 NW 185TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-2841
Mailing Address - Country:US
Mailing Address - Phone:305-491-6104
Mailing Address - Fax:954-391-9902
Practice Address - Street 1:3500 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5600
Practice Address - Country:US
Practice Address - Phone:305-491-6104
Practice Address - Fax:954-391-9902
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-30
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health