Provider Demographics
NPI:1659690907
Name:BULLOCK, MARK B (LPC, LMHC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:B
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 SW MACADAM AVE
Mailing Address - Street 2:580
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-6103
Mailing Address - Country:US
Mailing Address - Phone:503-290-3263
Mailing Address - Fax:
Practice Address - Street 1:5200 SW MACADAM AVE
Practice Address - Street 2:SUITE 580
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-6103
Practice Address - Country:US
Practice Address - Phone:503-290-3263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4410101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health