Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XN1300X | Occupational Therapist - Neurorehabilitation | 106101 | MN |
NPI | 1235760752 |
---|---|
Provider Name | Kyle Kelley Buck |
First Address | Minneapolis, MN 55408-1451 |
Second Address | Minneapolis, MN 55407-3723 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/02/2020 |
Last Update Date | 03/02/2020 |