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General NPI Number Information
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NPI Number | 1295505014
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Entity Type | Individual
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Provider Name | BLAKE A BULLOCK LCSW
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Gender | Male
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Dates
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Enumeration Date | 01/03/2024
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Last Update Date | 07/02/2025
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Provider Practice Location Address
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Address Line | 708 CHURCH ST STE 223
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City | EVANSTON
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State | IL
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Zip | 60201-3881
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Country | US
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Telephone | 312-620-0396
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Fax |
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Provider Business Mailing Address
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Address Line | 1649 W PRATT BLVD APT 3B
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City | CHICAGO
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State | IL
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Zip | 60626-4127
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Country | US
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Telephone | 309-540-8401
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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 | 149.024395
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License Number State | IL
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