Provider Demographics
NPI:1316432610
Name:BULLIS, RENEE (DPT)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:BULLIS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 3RD AVE SW STE 102
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-5736
Mailing Address - Country:US
Mailing Address - Phone:319-200-6102
Mailing Address - Fax:
Practice Address - Street 1:101 3RD AVE SW STE 102
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-5736
Practice Address - Country:US
Practice Address - Phone:319-200-6102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018020774225100000X
IA0961332251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist