Provider Demographics
NPI:1669729877
Name:BULLOCK, ALICIA MARIE (LCSWA, LCASA)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LCSWA, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10338 SAMUELS WAY DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7629
Mailing Address - Country:US
Mailing Address - Phone:252-799-7071
Mailing Address - Fax:
Practice Address - Street 1:284 EXECUTIVE PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1831
Practice Address - Country:US
Practice Address - Phone:704-939-1100
Practice Address - Fax:704-939-1173
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NCP0074771041C0700X
NC2976A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)