Provider Demographics
NPI:1922239532
Name:BULLOCK, STACEY (SLP)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
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 1:5731 STONEKIRK WALK NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6920
Mailing Address - Country:US
Mailing Address - Phone:770-975-8369
Mailing Address - Fax:
Practice Address - Street 1:5150 STILESBORO RD NW STE 410
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7759
Practice Address - Country:US
Practice Address - Phone:770-218-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006129235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist