| Doctor Name: | KRISTAN M BULLOCK |
| NPI Number: | 1689082521 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | M.S., CCC-SLP |
| License Number: | SLP 2623 |
| Business Practice Address: | 3715 Woodking Dr Idaho Falls, ID - 834044720 |
| Business Phone Number: | 2085292255 |
| Business Fax Number: | |
| Mailing Address: | 2094 Autumn Ln, IDAHO FALLS |
| State: | ID |
| Postal Code: | 834048287 |
| Phone Number: | 2088811309 |
| Fax Number: | |
| NPI Enumeration Date: | 07/23/2014 |
| NPI Last Update Date: | 09/15/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | SLP 2623 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |