Provider Demographics
NPI:1598924516
Name:BULLOCK, ANDREA SHANTZ (LPC)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:SHANTZ
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 1:417 N MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-4376
Mailing Address - Country:US
Mailing Address - Phone:704-636-5522
Mailing Address - Fax:704-636-5533
Practice Address - Street 1:417 N MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-4376
Practice Address - Country:US
Practice Address - Phone:704-636-5522
Practice Address - Fax:704-636-5533
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3175101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health