Provider Demographics
NPI:1881029692
Name:BULLOCK, ANDREA (LMP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 S 50TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-3417
Mailing Address - Country:US
Mailing Address - Phone:509-901-8227
Mailing Address - Fax:
Practice Address - Street 1:402 W WASHINGTON AVE APT E
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98903-1400
Practice Address - Country:US
Practice Address - Phone:509-453-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60400375225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist