Basic Information
| Provider Information | |||||||||
| NPI: | 1023546694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUCK | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | OTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 CLAYTON AVE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021556405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817759506 | ||||||||
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| Practice Location | |||||||||
| Address1: | 932 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | CHELSEA | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021502213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178892250 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2017 | ||||||||
| LastUpdateDate: | 05/26/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 2609 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.