Provider Demographics
NPI:1700056165
Name:BULLIS, TINA LEE (COTA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LEE
Last Name:BULLIS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14598 BERRINGER LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-4482
Mailing Address - Country:US
Mailing Address - Phone:352-359-0893
Mailing Address - Fax:
Practice Address - Street 1:14598 BERRINGER LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-4482
Practice Address - Country:US
Practice Address - Phone:352-359-0893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-01
Last Update Date:2008-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 9384224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant