Provider Demographics
NPI:1740066752
Name:BULLOCK, MICHELE LYNN (LMT)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYNN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 ELWOOD CT APT 303
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-0939
Mailing Address - Country:US
Mailing Address - Phone:360-738-6465
Mailing Address - Fax:
Practice Address - Street 1:1112 FINNEGAN WAY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-6622
Practice Address - Country:US
Practice Address - Phone:360-527-9566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61465321225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist