Provider Demographics
NPI:1063284875
Name:GRAHAM-BULLOCK, ERICA RENE
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:RENE
Last Name:GRAHAM-BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ERICA
Other - Middle Name:RENE
Other - Last Name:GRAHAM-BULLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3656 GINGER ST
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-7825
Mailing Address - Country:US
Mailing Address - Phone:818-818-1817
Mailing Address - Fax:
Practice Address - Street 1:3656 GINGER ST
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-7825
Practice Address - Country:US
Practice Address - Phone:818-818-1817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA331881331320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities