Healthcare Provider Details

I. General information

NPI: 1265708564
Provider Name (Legal Business Name): KIMBERLY ANTOINETTE BULLOCK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17657 132ND AVE
JAMAICA NY
11434-5839
US

IV. Provider business mailing address

17657 132ND AVE
JAMAICA NY
11434-5839
US

V. Phone/Fax

Practice location:
  • Phone: 718-712-1790
  • Fax: 516-292-7008
Mailing address:
  • Phone: 718-712-1790
  • Fax: 516-292-7008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number075392
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: