Provider Demographics
NPI:1770715138
Name:BOUCK, TONI EDWARDS (OTR,)
Entity type:Individual
Prefix:MRS
First Name:TONI
Middle Name:EDWARDS
Last Name:BOUCK
Suffix:
Gender:F
Credentials:OTR,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3331 SUMMIT BLVD APT 172
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-4331
Mailing Address - Country:US
Mailing Address - Phone:850-741-6715
Mailing Address - Fax:
Practice Address - Street 1:3964 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:FL
Practice Address - Zip Code:32565-1104
Practice Address - Country:US
Practice Address - Phone:850-741-6715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-19
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27-0596759273Y00000X
FL12040225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No273Y00000XHospital UnitsRehabilitation Unit