Provider Demographics
NPI:1750714374
Name:BULLOCK, KRISTINE DANA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:DANA
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12889 S SILVER PLUME ST
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-7485
Mailing Address - Country:US
Mailing Address - Phone:303-601-5620
Mailing Address - Fax:
Practice Address - Street 1:1012 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-3323
Practice Address - Country:US
Practice Address - Phone:303-601-5620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0001897235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist