Provider Demographics
NPI:1821185174
Name:BULLOCK, IZORA LAVERNE
Entity Type:Individual
Prefix:MRS
First Name:IZORA
Middle Name:LAVERNE
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 1:707 OAKPOINT CIR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-8694
Mailing Address - Country:US
Mailing Address - Phone:863-229-2764
Mailing Address - Fax:863-229-2764
Practice Address - Street 1:707 OAKPOINT CIR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8694
Practice Address - Country:US
Practice Address - Phone:863-229-2764
Practice Address - Fax:863-229-2764
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist