Provider Demographics
NPI:1437550498
Name:BULLOCK, KATIE (LMFT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5232 SHASTA DAM BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:96019-9398
Mailing Address - Country:US
Mailing Address - Phone:530-605-4373
Mailing Address - Fax:
Practice Address - Street 1:5232 SHASTA DAM BLVD STE C
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE
Practice Address - State:CA
Practice Address - Zip Code:96019-9398
Practice Address - Country:US
Practice Address - Phone:530-605-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-09
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106669106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist