Healthcare Provider Details

I. General information

NPI: 1003196122
Provider Name (Legal Business Name): JOSHUA STEPHEN BULLOCK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2011
Last Update Date: 08/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 BOSTON POST RD 2ND FLOOR
WEST HAVEN CT
06516-2043
US

IV. Provider business mailing address

114 BOSTON POST RD 2ND FLOOR
WEST HAVEN CT
06516-2043
US

V. Phone/Fax

Practice location:
  • Phone: 203-479-8000
  • Fax: 203-479-8001
Mailing address:
  • Phone: 203-479-8000
  • Fax: 203-479-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS01241
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: