Provider Demographics
NPI:1902458037
Name:BULLOCK, MARY ALISA (LPCA, LCASA, NCC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALISA
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LPCA, LCASA, NCC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ALISA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAIDEN
Mailing Address - Street 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:1104A S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-3134
Practice Address - Country:US
Practice Address - Phone:336-242-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25659101YA0400X
NCA14910101YM0800X
NC14910101YP2500X
NCLCAS-25659101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101YP2500XOtherSTATE OF NC
NC101YA0400XOtherSTATE OF NC