Provider Demographics
NPI:1861876476
Name:BULLOCK, ANDREA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials: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:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:HONEYVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84314-0351
Mailing Address - Country:US
Mailing Address - Phone:435-730-7781
Mailing Address - Fax:
Practice Address - Street 1:7135 NORTH 2350 WEST
Practice Address - Street 2:
Practice Address - City:HONEYVILLE
Practice Address - State:UT
Practice Address - Zip Code:84314
Practice Address - Country:US
Practice Address - Phone:435-730-7781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6248795-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist