| Doctor Name: | DR. MARK DANA BULLOCK |
| NPI Number: | 1346370277 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PH.D. |
| License Number: | LPC-988 |
| Business Practice Address: | 6160 E Hayden Lake Rd Hayden, ID - 838357594 |
| Business Phone Number: | 2086998044 |
| Business Fax Number: | |
| Mailing Address: | 6160 E Hayden Lake Rd, HAYDEN |
| State: | ID |
| Postal Code: | 838357594 |
| Phone Number: | 2086998044 |
| Fax Number: | |
| NPI Enumeration Date: | 03/07/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | LPC-988 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |