Healthcare Provider Details

I. General information

NPI: 1265273908
Provider Name (Legal Business Name): SAMUEL BULLOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2277 SUNSET BLVD
WEST COLUMBIA SC
29169-4713
US

IV. Provider business mailing address

2277 SUNSET BLVD
WEST COLUMBIA SC
29169-4713
US

V. Phone/Fax

Practice location:
  • Phone: 888-796-1117
  • Fax: 803-996-5228
Mailing address:
  • Phone: 888-796-1117
  • Fax: 803-996-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number10394
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: