Provider Demographics
NPI:1346594603
Name:BULLOCK, KARA S
Entity Type:Individual
Prefix:MRS
First Name:KARA
Middle Name:S
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 N 57TH PL
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72904-7343
Mailing Address - Country:US
Mailing Address - Phone:479-422-3592
Mailing Address - Fax:
Practice Address - Street 1:3205 JENNY LIND RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-7101
Practice Address - Country:US
Practice Address - Phone:479-785-2501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116050743Medicaid