Healthcare Provider Details

I. General information

NPI: 1457526337
Provider Name (Legal Business Name): MATT KEVIN BULLOCH L.P.C. NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 11/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 W HIGHWAY 56 #5
CEDAR CITY UT
84720-4118
US

IV. Provider business mailing address

1009 IRONWOOD CIR
CEDAR CITY UT
84721-5125
US

V. Phone/Fax

Practice location:
  • Phone: 435-327-2137
  • Fax:
Mailing address:
  • Phone: 435-327-2137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2785863-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2785863-6004
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: