Provider Demographics
NPI:1447323431
Name:BULLER, MYRA D (PT, CST)
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:D
Last Name:BULLER
Suffix:
Gender:F
Credentials:PT, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8015 ROD LAVER AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810
Mailing Address - Country:US
Mailing Address - Phone:504-495-6855
Mailing Address - Fax:225-767-0423
Practice Address - Street 1:8015 ROD LAVER AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810
Practice Address - Country:US
Practice Address - Phone:504-495-6855
Practice Address - Fax:225-767-0423
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA00619225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist