MEDICARE: KAREN BULLOCK PH.D., LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	006182	CT

General Provider Information

NPI Number	:	1275560823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN BULLOCK PH.D., LCSW

Provider Business Mailing Address
First Line	:	PO BOX 40,000 DEPT 634
Second Line	:	HARTFORD HOSPITAL PROFESSIONAL SERVICES
City	:	HARTFORD
State	:	CT
Zip	:	06151-0634
Country	:	US
Telephone Number	:	860-545-7602
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 RETREAT AVE
Second Line	:	HARTFORD HOSPITAL GERIATRIC PSYCHIATRY
City	:	HARTFORD
State	:	CT
Zip	:	06106-3310
Country	:	US
Telephone Number	:	860-545-7189
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	03/02/2010

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