Provider Demographics
NPI:1316125958
Name:BULLOCK, SAUNDRA GAYLE (LISAC)
Entity type:Individual
Prefix:
First Name:SAUNDRA
Middle Name:GAYLE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 WEST SEEDFARM ROAD
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247-0038
Mailing Address - Country:US
Mailing Address - Phone:602-528-3321
Mailing Address - Fax:602-528-1374
Practice Address - Street 1:483 WEST SEEDFARM ROAD
Practice Address - Street 2:HUHUKAM HOSPITAL
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247-0038
Practice Address - Country:US
Practice Address - Phone:602-528-7146
Practice Address - Fax:602-528-1374
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-11536101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLISC-11536Medicaid