Provider Demographics
NPI:1346370277
Name:BULLOCK, MARK DANA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DANA
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6160 E HAYDEN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-7594
Mailing Address - Country:US
Mailing Address - Phone:208-699-8044
Mailing Address - Fax:
Practice Address - Street 1:6160 E HAYDEN LAKE RD
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-7594
Practice Address - Country:US
Practice Address - Phone:208-699-8044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-988101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health