Provider Demographics
NPI:1356116669
Name:BULLOCK, MICHELLE GRACE TATKO (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GRACE TATKO
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 LITTLE RAVEN ST APT 239
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-7150
Mailing Address - Country:US
Mailing Address - Phone:509-939-2304
Mailing Address - Fax:
Practice Address - Street 1:18551 E 160TH AVE
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-8519
Practice Address - Country:US
Practice Address - Phone:303-655-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-16
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24377829235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist