Provider Demographics
NPI:1922865740
Name:BULLOCK, KELSEY (SLP)
Entity Type:Individual
Prefix:
First Name:KELSEY
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 1:7 BARLEY FIELD PL
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-2927
Mailing Address - Country:US
Mailing Address - Phone:802-683-9702
Mailing Address - Fax:
Practice Address - Street 1:117 TEMPLE ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-3530
Practice Address - Country:US
Practice Address - Phone:802-786-1729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT144.0134510235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist