Provider Demographics
NPI:1639354335
Name:BULLOCK, MISTY STAR
Entity Type:Individual
Prefix:MISS
First Name:MISTY
Middle Name:STAR
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 1:2032 S FRAZIER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-5618
Mailing Address - Country:US
Mailing Address - Phone:267-736-9099
Mailing Address - Fax:
Practice Address - Street 1:2032 S FRAZIER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-5618
Practice Address - Country:US
Practice Address - Phone:267-736-9099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-01
Last Update Date:2008-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC009582225X00000X
FLOT11929225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist