Provider Demographics
NPI:1487717443
Name:BULLOCK, HARRIET (MS, LMFT)
Entity type:Individual
Prefix:
First Name:HARRIET
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 NEW GARDEN RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-2529
Mailing Address - Country:US
Mailing Address - Phone:336-288-0588
Mailing Address - Fax:336-288-0517
Practice Address - Street 1:2012 NEW GARDEN RD
Practice Address - Street 2:SUITE E
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2529
Practice Address - Country:US
Practice Address - Phone:336-288-0588
Practice Address - Fax:336-288-0517
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLMFT 703106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14027OtherBCBS
NC6105106Medicaid