Provider Demographics
NPI:1720705205
Name:BULLINGTON, MARY AMANDA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:AMANDA
Last Name:BULLINGTON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:MARY AMANDA
Other - Middle Name:BULLINGTON
Other - Last Name:CUNNINGHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:785 FATHER JUDGE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:VA
Mailing Address - Zip Code:24574-2734
Mailing Address - Country:US
Mailing Address - Phone:434-665-8145
Mailing Address - Fax:
Practice Address - Street 1:2839 BISHOP CREEK RD
Practice Address - Street 2:
Practice Address - City:LYNCH STATION
Practice Address - State:VA
Practice Address - Zip Code:24571-2445
Practice Address - Country:US
Practice Address - Phone:434-941-8185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006193235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist