Provider Demographics
NPI:1558547406
Name:BULLA, CARLA J (PT, DPT)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:J
Last Name:BULLA
Suffix:
Gender:F
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 1:294 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-3510
Mailing Address - Country:US
Mailing Address - Phone:850-331-3017
Mailing Address - Fax:855-975-2575
Practice Address - Street 1:638 N FERDON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2170
Practice Address - Country:US
Practice Address - Phone:850-331-3017
Practice Address - Fax:855-975-2575
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL21832255A2300X
FLPT23814225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103517900Medicaid