Healthcare Provider Details

I. General information

NPI: 1932554094
Provider Name (Legal Business Name): CATHY BULLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 E 52ND ST
INDIANAPOLIS IN
46205-1486
US

IV. Provider business mailing address

2021 E 52ND ST
INDIANAPOLIS IN
46205-1486
US

V. Phone/Fax

Practice location:
  • Phone: 317-490-5526
  • Fax:
Mailing address:
  • Phone: 317-490-5526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number1013863-1
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number1013863-1
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number1013863-1
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: