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NPI Code Detail

MEDICARE: EVAN BULLOCK

MEDICARE: EVAN BULLOCK
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1224Z00000XOccupational Therapy Assistant

General Provider Information

NPI Number : 1891689394
Entity Type Code : Individual
Provider Name (Legal Business Name) : EVAN BULLOCK
Provider Business Mailing Address
First Line : 5277 E MARYLAND ST
Second Line :
City : DECATUR
State : IL
Zip : 62521-9705
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 5277 E MARYLAND ST
Second Line :
City : DECATUR
State : IL
Zip : 62521-9705
Country : US
Telephone Number : 217-408-5091
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/07/2025
Last Update Date : 06/07/2025

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Directions to “ EVAN BULLOCK ” Practice Location

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