Provider Demographics
NPI:1508273244
Name:BULLOCK, DANA
Entity Type:Individual
Prefix:MISS
First Name:DANA
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 1:7727 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-4320
Mailing Address - Country:US
Mailing Address - Phone:612-455-0304
Mailing Address - Fax:612-861-0186
Practice Address - Street 1:7727 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-4320
Practice Address - Country:US
Practice Address - Phone:612-455-0304
Practice Address - Fax:612-861-0186
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201944224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant