Provider Demographics
NPI:1134249592
Name:BOULLY, MICHAEL JAMES JR (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:BOULLY
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6021 ROLLING VISTA LOOP
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:FL
Mailing Address - Zip Code:33527-4268
Mailing Address - Country:US
Mailing Address - Phone:813-759-8761
Mailing Address - Fax:
Practice Address - Street 1:1513 SUN CITY CENTER PLZ
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5390
Practice Address - Country:US
Practice Address - Phone:813-634-6022
Practice Address - Fax:813-634-6053
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18461225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist