Provider Demographics
NPI:1255626388
Name:BULLOCK, KATHY
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
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 1:1892 W 1590 S
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-2474
Mailing Address - Country:US
Mailing Address - Phone:801-913-5879
Mailing Address - Fax:
Practice Address - Street 1:5974 FASHION POINT DR
Practice Address - Street 2:STE 100
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4699
Practice Address - Country:US
Practice Address - Phone:801-479-9644
Practice Address - Fax:801-479-9639
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5597738-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant