Healthcare Provider Details

I. General information

NPI: 1346501145
Provider Name (Legal Business Name): ELIZABETH BULLOCK M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH ARNOLD

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 FARRELL DR
COVINGTON KY
41011-3717
US

IV. Provider business mailing address

503 FARRELL DR
COVINGTON KY
41011-3775
US

V. Phone/Fax

Practice location:
  • Phone: 859-578-3200
  • Fax:
Mailing address:
  • Phone: 859-578-3200
  • Fax: 859-534-2989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number239610
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: