MEDICARE: MRS. MICHELLE EILEEN BUCK OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XL0004X	Low Vision Occupational Therapist	5201006345	MI

General Provider Information

NPI Number	:	1679074553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE EILEEN BUCK OTR/L

Provider Business Mailing Address
First Line	:	15401 E JEFFERSON AVE
Second Line	:
City	:	GROSSE POINTE PARK
State	:	MI
Zip	:	48230-1328
Country	:	US
Telephone Number	:	313-824-2401
Fax Number	:

Provider Business Practice Location Address
First Line	:	15401 E JEFFERSON AVE
Second Line	:
City	:	GROSSE POINTE PARK
State	:	MI
Zip	:	48230-1328
Country	:	US
Telephone Number	:	313-824-2401
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2018
Last Update Date	:	03/17/2018

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