Healthcare Provider Details

I. General information

NPI: 1891320370
Provider Name (Legal Business Name): KYLIE BUMA OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYLIE VAN ROEKEL

II. Dates (important events)

Enumeration Date: 03/05/2020
Last Update Date: 03/05/2020
Certification Date: 03/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 STEVENS DR STE 1E
RICHLAND WA
99352-3523
US

IV. Provider business mailing address

925 STEVENS DR STE 1E
RICHLAND WA
99352-3523
US

V. Phone/Fax

Practice location:
  • Phone: 509-942-8474
  • Fax:
Mailing address:
  • Phone: 509-942-8474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT61043185
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: