Provider Demographics
NPI:1801529086
Name:BULLOCK, BAILEY (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2557 PEMBROKE RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4712
Mailing Address - Country:US
Mailing Address - Phone:980-320-8275
Mailing Address - Fax:704-973-7862
Practice Address - Street 1:2557 PEMBROKE RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4712
Practice Address - Country:US
Practice Address - Phone:980-320-8275
Practice Address - Fax:704-973-7862
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15117225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics