MEDICARE: ABIGAIL ROSE LEI BULLOCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	C10900	OR

General Provider Information

NPI Number	:	1821670670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABIGAIL ROSE LEI BULLOCK

Provider Business Mailing Address
First Line	:	1942 NW KEARNEY ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-1426
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1942 NW KEARNEY ST STE 11
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-1463
Country	:	US
Telephone Number	:	503-610-5567
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2021
Last Update Date	:	12/11/2025

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