Provider Demographics
NPI:1831224716
Name:BULLOCK, MARY D (OTRL)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:D
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 STONY POINT PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-1962
Mailing Address - Country:US
Mailing Address - Phone:804-545-9435
Mailing Address - Fax:804-545-9440
Practice Address - Street 1:8700 STONY POINT PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-1962
Practice Address - Country:US
Practice Address - Phone:804-545-9435
Practice Address - Fax:804-545-9440
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119000662225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA002799R89Medicare ID - Type Unspecified