Healthcare Provider Details

I. General information

NPI: 1093143091
Provider Name (Legal Business Name): TAMEKA BULLOCK LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7105 REDWOOD BRANCH CT
CLINTON MD
20735-5812
US

IV. Provider business mailing address

7105 REDWOOD BRANCH CT
CLINTON MD
20735-5812
US

V. Phone/Fax

Practice location:
  • Phone: 240-299-5985
  • Fax:
Mailing address:
  • Phone: 240-299-5985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14710
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: