Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | ||
Y | 103T00000X | Psychologist |
NPI | 1003043696 |
---|---|
Provider Name | Dr. Chester Wayne Bullock JR. |
First Address | Washington, DC 20037-1498 |
Second Address | Washington, DC 20037-1498 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2009 |
Last Update Date | 18/03/2016 |