Provider Demographics
NPI:1235021908
Name:BULLOCK, STEPHEN J (CDCA192853)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:CDCA192853
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 LORI LN
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2610
Mailing Address - Country:US
Mailing Address - Phone:937-979-5243
Mailing Address - Fax:
Practice Address - Street 1:7593 TYLERS PLACE BLVD
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-6308
Practice Address - Country:US
Practice Address - Phone:513-714-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.1928531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical