Individual
MARY ALISA BULLOCK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LPCA, LCASA, NCC
Contact information
Practice address
1104A S MAIN ST, LEXINGTON, NC 27292-3134
(336) 242-2450
Mailing address
284 EXECUTIVE PARK DR STE 100, CONCORD, NC 28025-1833
(704) 939-1100
(704) 939-1173
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
25659
NC
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
LCAS-25659
NC
101YM0800X
Mental Health Counselor
A14910
NC
101YP2500X
Professional Counselor
14910
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
101YA0400X
STATE OF NC
NC
01
—
101YP2500X
STATE OF NC
NC
Enumeration date
07/09/2019
Last updated
12/01/2022
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