Basic Information
| Provider Information | |||||||||
| NPI: | 1821265307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED, LPC, NCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FISSEL | ||||||||
| OtherFirstName: | CHRISTINA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 252 CALLOWAY CT | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702437514 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Practice Location | |||||||||
| Address1: | 252 CALLOWAY CT | ||||||||
| Address2: | |||||||||
| City: | EVANS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702437514 | ||||||||
| FaxNumber: | 8709339395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2008 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | P1201007 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 5AA34 | 01 | AR | BCBS | OTHER | 169571795 | 05 | AR | MEDICAID |