Healthcare Provider Details

I. General information

NPI: 1851642169
Provider Name (Legal Business Name): MEAGAN MARIE BULLOCK LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 RANDOLPH RD SUITE 800
CHARLOTTE NC
28207-1122
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-1246
  • Fax: 704-384-6072
Mailing address:
  • Phone: 704-384-1246
  • Fax: 704-384-6072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP007635
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: