Provider Demographics
NPI:1376115147
Name:BULLOCK, SHELBY (PTA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:800 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-2624
Mailing Address - Country:US
Mailing Address - Phone:660-525-3028
Mailing Address - Fax:
Practice Address - Street 1:1300 VETERANS RD
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-8294
Practice Address - Country:US
Practice Address - Phone:660-543-5064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016037538225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant