Healthcare Provider Details

I. General information

NPI: 1407874084
Provider Name (Legal Business Name): CANDICE J BUKEVICZ MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 WELLES ST
FORTY FORT PA
18704-4968
US

IV. Provider business mailing address

610 WYOMING AVE
KINGSTON PA
18704-3702
US

V. Phone/Fax

Practice location:
  • Phone: 570-714-4171
  • Fax: 570-714-4188
Mailing address:
  • Phone: 570-288-5441
  • Fax: 570-288-5842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT007548L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: