Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | ||
Y | 103T00000X | Psychologist | ||
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | ||
N | 103TA0700X | Adult Development & Aging Psychologist | ||
N | 103TB0200X | Cognitive & Behavioral Psychologist | ||
N | 103TE1100X | Exercise & Sports Psychologist | ||
N | 103TF0000X | Family Psychologist | ||
N | 103TH0004X | Health Psychologist | ||
N | 103TP2701X | Group Psychotherapist |
NPI | 1356590442 |
---|---|
Provider Name | B Grace Marie Bullock |
First Address | Eugene, OR 97405-2794 |
Second Address | Eugene, OR 97405-2794 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2008 |
Last Update Date | 25/10/2012 |