Basic Information
| Provider Information | |||||||||
| NPI: | 1679082952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLOCH | ||||||||
| FirstName: | MICAH | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | SSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 474 W 200 N | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847704505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356345600 | ||||||||
| FaxNumber: | 4359868700 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 E 680 S | ||||||||
| Address2: | |||||||||
| City: | CEDAR CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847203593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358677654 | ||||||||
| FaxNumber: | 4358677699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2017 | ||||||||
| LastUpdateDate: | 09/29/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | UT | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.