Provider Demographics
NPI:1811371156
Name:BULT, JOHN (LPTA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:BULT
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6506 BEVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-5220
Mailing Address - Country:US
Mailing Address - Phone:202-236-7535
Mailing Address - Fax:
Practice Address - Street 1:6506 BEVERLY AVE
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-5220
Practice Address - Country:US
Practice Address - Phone:202-236-7535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604175225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant