Provider Demographics
NPI:1164061016
Name:BULLOCK, STEPHEN S (LMT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:S
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 SW 4TH AVE APT 313
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5531
Mailing Address - Country:US
Mailing Address - Phone:443-562-9635
Mailing Address - Fax:
Practice Address - Street 1:1720 SW 4TH AVE APT 313
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5531
Practice Address - Country:US
Practice Address - Phone:443-562-9635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-24
Last Update Date:2019-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25530225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist