Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 2609 | MA |
NPI | 1023546694 |
---|---|
Provider Name | Laura Ruck |
First Address | Medford, MA 02155-6405 |
Second Address | Chelsea, MA 02150-2213 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/05/2017 |
Last Update Date | 26/05/2017 |