Provider Demographics
NPI:1336545094
Name:BULLOCK, CARA STALEY (SLP)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:STALEY
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 1:11801 BERWICK CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-1871
Mailing Address - Country:US
Mailing Address - Phone:540-710-6865
Mailing Address - Fax:
Practice Address - Street 1:600 JACKSON ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5719
Practice Address - Country:US
Practice Address - Phone:540-373-3223
Practice Address - Fax:540-371-3753
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-07
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004983235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist