Healthcare Provider Details

I. General information

NPI: 1073223665
Provider Name (Legal Business Name): LIAMARA BULLOCK AA, CPSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2022
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 COMMERCE AVE
LONGVIEW WA
98632-3756
US

IV. Provider business mailing address

PO BOX 2394
LONGVIEW WA
98632-8455
US

V. Phone/Fax

Practice location:
  • Phone: 360-998-2047
  • Fax: 360-200-6736
Mailing address:
  • Phone: 360-200-5419
  • Fax: 944-612-6673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number61377319
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPR70110892
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: