Healthcare Provider Details

I. General information

NPI: 1346370277
Provider Name (Legal Business Name): MARK DANA BULLOCK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 E HAYDEN LAKE RD
HAYDEN ID
83835-7594
US

IV. Provider business mailing address

6160 E HAYDEN LAKE RD
HAYDEN ID
83835-7594
US

V. Phone/Fax

Practice location:
  • Phone: 208-699-8044
  • Fax:
Mailing address:
  • Phone: 208-699-8044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-988
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: