Healthcare Provider Details

I. General information

NPI: 1740119742
Provider Name (Legal Business Name): DANIELLE SIMONE BULLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5814 OLD PASCO RD
WESLEY CHAPEL FL
33544-4011
US

IV. Provider business mailing address

2206 KENDALL SPRINGS CT APT 102
BRANDON FL
33510-2491
US

V. Phone/Fax

Practice location:
  • Phone: 908-938-1577
  • Fax:
Mailing address:
  • Phone: 813-731-7870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberB420177837460
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: