Provider Demographics
NPI:1023496718
Name:BULLOCK, IVY
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FARMINGDALE ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-0704
Mailing Address - Country:US
Mailing Address - Phone:631-647-5991
Mailing Address - Fax:
Practice Address - Street 1:240 LONG ISLAND AVE
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-3123
Practice Address - Country:US
Practice Address - Phone:631-782-6200
Practice Address - Fax:631-491-5354
Is Sole Proprietor?:No
Enumeration Date:2015-05-13
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083420104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker