Healthcare Provider Details

I. General information

NPI: 1386914117
Provider Name (Legal Business Name): DAVETTE VENITA RUCKER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6524 LUZON AVE NW #24
WASHINGTON DC
20012-3010
US

IV. Provider business mailing address

6524 LUZON AVE NW #24
WASHINGTON DC
20012-3010
US

V. Phone/Fax

Practice location:
  • Phone: 202-431-2555
  • Fax: 202-545-9497
Mailing address:
  • Phone: 202-431-2555
  • Fax: 202-545-9497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XE0001X
TaxonomyEnvironmental Modification Occupational Therapist
License Number04134
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: