Provider Demographics
NPI:1033070412
Name:RIVENS BULLEN, AQILAH
Entity type:Individual
Prefix:
First Name:AQILAH
Middle Name:
Last Name:RIVENS BULLEN
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 1:5840 E WT HARRIS BLVD
Mailing Address - Street 2:STE 109 PMB 1074
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215
Mailing Address - Country:US
Mailing Address - Phone:646-739-6249
Mailing Address - Fax:
Practice Address - Street 1:5840 E WT HARRIS BLVD
Practice Address - Street 2:STE 109 PMB 1074
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215
Practice Address - Country:US
Practice Address - Phone:646-739-6249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-24
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22791225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist