Healthcare Provider Details

I. General information

NPI: 1871897108
Provider Name (Legal Business Name): TAKIA L BULLOCK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2010
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27251 WESLEY CHAPEL BLVD STE 1189
WESLEY CHAPEL FL
33544-4285
US

IV. Provider business mailing address

27251 WESLEY CHAPEL BLVD STE 1189
WESLEY CHAPEL FL
33544-4285
US

V. Phone/Fax

Practice location:
  • Phone: 727-662-9198
  • Fax:
Mailing address:
  • Phone: 727-662-9198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25163
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: