Basic Information
| Provider Information | |||||||||
| NPI: | 1487258299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLOCH | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | AUSTIN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CSW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 235 S 200 E | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840252320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017911588 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 235 S 200 E | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840252320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017911588 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2020 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 11615012-3502 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.