Provider Demographics
NPI:1730556366
Name:BUCK, MICAH (OTR/L)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:BUCK
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:892 CANYON RIM RD
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-0025
Mailing Address - Country:US
Mailing Address - Phone:208-283-6084
Mailing Address - Fax:
Practice Address - Street 1:803 HARRISON ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3925
Practice Address - Country:US
Practice Address - Phone:208-732-1503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT958225X00000X
IDOT-958225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist