Provider Demographics
NPI:1255526752
Name:BULLOCK, PAIGE KIMBERLY (PT)
Entity type:Individual
Prefix:MISS
First Name:PAIGE
Middle Name:KIMBERLY
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1531
Mailing Address - Country:US
Mailing Address - Phone:516-361-9838
Mailing Address - Fax:
Practice Address - Street 1:25 ELIZABETH ST
Practice Address - Street 2:APT 2K
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-1900
Practice Address - Country:US
Practice Address - Phone:516-361-9838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-08
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NY024603225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist