Provider Demographics
NPI:1447934245
Name:BULLUCK, DEJA TATYANA
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:TATYANA
Last Name:BULLUCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 STODDARD CT APT 202
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-5610
Mailing Address - Country:US
Mailing Address - Phone:202-805-1057
Mailing Address - Fax:
Practice Address - Street 1:1110 HERNDON PKWY STE 205
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-5547
Practice Address - Country:US
Practice Address - Phone:571-305-1906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist