Provider Demographics
NPI:1164900502
Name:BULLOCK, FATIMA QUEENNEL (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:FATIMA
Middle Name:QUEENNEL
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5402 MILROY RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46216-2088
Mailing Address - Country:US
Mailing Address - Phone:317-869-8826
Mailing Address - Fax:
Practice Address - Street 1:5402 MILROY RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-2088
Practice Address - Country:US
Practice Address - Phone:317-869-8826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-28
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004003A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty