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General NPI Number Information
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NPI Number | 1871297564
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Entity Type | Individual
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Provider Name | ANDREA DENISE BULLOCK
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Gender | Female
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Dates
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Enumeration Date | 03/28/2023
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Last Update Date | 03/28/2023
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Provider Practice Location Address
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Address Line | 12636 BLOOMFIELD AVE APT 51
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City | NORWALK
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State | CA
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Zip | 90650-1411
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Country | US
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Telephone | 310-228-7577
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Fax |
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Provider Business Mailing Address
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Address Line | 14445 OLIVE VIEW DR # 1D120
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City | SYLMAR
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State | CA
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Zip | 91342-1437
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Country | US
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Telephone | 747-210-4204
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225800000X
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Taxonomy Name | Recreation Therapist
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License Number | 5303-T
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License Number State | CA
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