Provider Demographics
NPI:1487258299
Name:BULLOCH, ROBERT AUSTIN (CSW)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:AUSTIN
Last Name:BULLOCH
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 S 200 E
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2320
Mailing Address - Country:US
Mailing Address - Phone:801-791-1588
Mailing Address - Fax:
Practice Address - Street 1:235 S 200 E
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2320
Practice Address - Country:US
Practice Address - Phone:801-791-1588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11615012-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical