Healthcare Provider Details

I. General information

NPI: 1750135257
Provider Name (Legal Business Name): LAUREN BUCKNER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44225 W 12 MILE RD STE C-106
NOVI MI
48377-2640
US

IV. Provider business mailing address

12068 HELEN ST
SOUTHGATE MI
48195-1886
US

V. Phone/Fax

Practice location:
  • Phone: 248-277-3005
  • Fax:
Mailing address:
  • Phone: 313-670-6982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number5201013749
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: