Provider Demographics
NPI:1225204860
Name:BULLOCK, CHRYSTIN (BCBA)
Entity Type:Individual
Prefix:
First Name:CHRYSTIN
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:CHRYSTIN
Other - Middle Name:
Other - Last Name:DIBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:203 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-2621
Mailing Address - Country:US
Mailing Address - Phone:407-460-1021
Mailing Address - Fax:407-386-7033
Practice Address - Street 1:203 E 10TH ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-2621
Practice Address - Country:US
Practice Address - Phone:407-460-1021
Practice Address - Fax:407-386-7033
Is Sole Proprietor?:No
Enumeration Date:2008-05-04
Last Update Date:2008-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBCBA 1052521222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist