Provider Demographics
NPI:1821265307
Name:BULLOCK, CHRISTINA M (MED, LPC, NCC)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:M
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MED, LPC, NCC
Other - Prefix:MS
Other - First Name:CHRISTINA
Other - Middle Name:
Other - Last Name:FISSEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:252 CALLOWAY CT
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809
Mailing Address - Country:US
Mailing Address - Phone:870-243-7514
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:252 CALLOWAY CT
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809
Practice Address - Country:US
Practice Address - Phone:870-243-7514
Practice Address - Fax:870-933-9395
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1201007101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5AA34OtherBCBS
AR169571795Medicaid