Provider Demographics
NPI:1790204238
Name:BUCKINGHAM, SCOTT AUSTIN (OTRL)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:AUSTIN
Last Name:BUCKINGHAM
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8321 HAPPY TRL
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34747-1338
Mailing Address - Country:US
Mailing Address - Phone:407-489-4533
Mailing Address - Fax:
Practice Address - Street 1:3452 LAKE LYNDA DR STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-1481
Practice Address - Country:US
Practice Address - Phone:407-249-3168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17533225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty