Basic Information
| Provider Information | |||||||||
| NPI: | 1427729821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | DESIREE | ||||||||
| MiddleName: | KIMBERLY JANELLE | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 434 EASTLAND RD | ||||||||
| Address2: | |||||||||
| City: | BEREA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440171217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402342006 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2000 NOBLE DR | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446915353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302643232 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2021 | ||||||||
| LastUpdateDate: | 10/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | C.2103266-TRNE | OH | N | Behavioral Health & Social Service Providers | Counselor | 101Y00000X | C.2204687 | OH | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.