Provider Demographics
NPI:1295505014
Name:BULLOCK, BLAKE A (LCSW)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:A
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 SPRING CIR
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-7566
Mailing Address - Country:US
Mailing Address - Phone:309-540-8401
Mailing Address - Fax:
Practice Address - Street 1:206 SPRING CIR
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-7566
Practice Address - Country:US
Practice Address - Phone:309-540-8401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0243951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical