Provider Demographics
NPI:1730399775
Name:TULLOCK, LAURA ANN (OTR)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:ANN
Last Name:TULLOCK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:TULLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3120 COUNTY ROAD 244
Mailing Address - Street 2:
Mailing Address - City:MONROE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63456-2339
Mailing Address - Country:US
Mailing Address - Phone:314-398-1188
Mailing Address - Fax:573-588-0187
Practice Address - Street 1:218 E SHELBINA AVE
Practice Address - Street 2:
Practice Address - City:SHELBINA
Practice Address - State:MO
Practice Address - Zip Code:63468-4328
Practice Address - Country:US
Practice Address - Phone:573-588-0187
Practice Address - Fax:573-588-0187
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20000161702225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist