Provider Demographics
NPI:1467728725
Name:BULLOCK, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
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 1:11 SUNSET DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507
Mailing Address - Country:US
Mailing Address - Phone:774-230-6494
Mailing Address - Fax:
Practice Address - Street 1:11 SUNSET DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:MA
Practice Address - Zip Code:01507
Practice Address - Country:US
Practice Address - Phone:774-230-6494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114699225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist