Provider Demographics
NPI:1578037024
Name:BULLOCK, NATALIE DANIELLE (LPC)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:DANIELLE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 ASHFORD DR APT 1133
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-7849
Mailing Address - Country:US
Mailing Address - Phone:318-536-1592
Mailing Address - Fax:
Practice Address - Street 1:107 ASHFORD DR APT 1133
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7849
Practice Address - Country:US
Practice Address - Phone:318-536-1592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7751101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1417252230Medicaid