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General NPI Number Information
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NPI Number | 1063545978
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Entity Type | Individual
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Provider Name | LESLIE ELLEN BULLOCK MSW, LCSW
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Gender | Female
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Dates
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Enumeration Date | 03/13/2007
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Last Update Date | 09/28/2007
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Provider Practice Location Address
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Address Line | 5464 N PALM AVE STE B
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City | FRESNO
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State | CA
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Zip | 93704-1946
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Country | US
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Telephone | 559-908-0925
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Fax |
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Provider Business Mailing Address
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Address Line | 4619 N SAFFORD AVE
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City | FRESNO
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State | CA
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Zip | 93704-2920
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Country | US
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Telephone | 559-224-7674
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCS 23296
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License Number State | CA
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