=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023067386
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM C. BULLOCK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2006
-----------------------------------------------------
Last Update Date | 05/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3671 BUSINESS DR
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95820-2165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-734-6620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9785 WESTMINSTER WAY
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95757-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-734-6620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------