Provider Demographics
NPI:1053960047
Name:BULLOCK, DAVID ALEXANDER
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ALEXANDER
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17320 W 12 MILE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2102
Mailing Address - Country:US
Mailing Address - Phone:734-330-3663
Mailing Address - Fax:248-557-4697
Practice Address - Street 1:17320 W 12 MILE RD STE 101
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2102
Practice Address - Country:US
Practice Address - Phone:734-330-3663
Practice Address - Fax:248-557-4697
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty