Healthcare Provider Details

I. General information

NPI: 1679082952
Provider Name (Legal Business Name): MICAH J BULLOCH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 E 680 S
CEDAR CITY UT
84720-3593
US

IV. Provider business mailing address

2505 IDLEWILDE DR
MIDLAND TX
79707-6120
US

V. Phone/Fax

Practice location:
  • Phone: 435-867-7654
  • Fax: 435-867-7699
Mailing address:
  • Phone: 435-868-8405
  • Fax: 435-986-8700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number107800
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8371889
License Number StateID
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8765778-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: