Provider Demographics
NPI:1871997692
Name:BULLOCK, AMY (LCSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 W PHEASANT ST
Mailing Address - Street 2:
Mailing Address - City:HEBER
Mailing Address - State:CA
Mailing Address - Zip Code:92249-9658
Mailing Address - Country:US
Mailing Address - Phone:760-540-4335
Mailing Address - Fax:760-482-5696
Practice Address - Street 1:1073 ROSS AVE STE C
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4371
Practice Address - Country:US
Practice Address - Phone:760-540-4335
Practice Address - Fax:760-482-5696
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA619271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical