Healthcare Provider Details

I. General information

NPI: 1609005446
Provider Name (Legal Business Name): MICHAEL CRAIG BULLOCK MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 15TH ST
AUGUSTA GA
30901-2608
US

IV. Provider business mailing address

950 15TH ST
AUGUSTA GA
30901-2608
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax:
Mailing address:
  • Phone: 706-733-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW005575
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11196
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: