Provider Demographics
NPI:1568627347
Name:BULLOCK, KELLY LYN (SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 E 9400 S
Mailing Address - Street 2:STE 112
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3666
Mailing Address - Country:US
Mailing Address - Phone:801-840-4361
Mailing Address - Fax:
Practice Address - Street 1:870 E 9400 S STE 112
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3688
Practice Address - Country:US
Practice Address - Phone:801-571-3081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6975681-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist