Healthcare Provider Details

I. General information

NPI: 1356708580
Provider Name (Legal Business Name): HEIDI BULLOCK COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 OFFICE PARK CIRCLE SUITE 115
MOUNTAIN BROOK AL
35223
US

IV. Provider business mailing address

3 OFFICE PARK CIRCLE SUITE 115
MOUNTAIN BROOK AL
35223
US

V. Phone/Fax

Practice location:
  • Phone: 205-912-2000
  • Fax: 205-945-1890
Mailing address:
  • Phone: 205-912-2000
  • Fax: 205-945-1890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2267C
License Number StateAL

VIII. Authorized Official

Name: MS. HEIDI LYNN BULLOCK
Title or Position: PROVIDER-OWNER
Credential: LCSW/PIP
Phone: 317-650-1165