Provider Demographics
NPI:1245768621
Name:BULLOCK, GARRETT SCOTT (PT, DPT)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:SCOTT
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 36TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-1005
Mailing Address - Country:US
Mailing Address - Phone:304-917-3660
Mailing Address - Fax:304-917-3674
Practice Address - Street 1:47 DEPOT ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:VA
Practice Address - Zip Code:24531-5518
Practice Address - Country:US
Practice Address - Phone:434-432-0028
Practice Address - Fax:434-432-0062
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211086225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist