Provider Demographics
NPI:1780296897
Name:KLUCK, TAYLOR (COTA)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:KLUCK
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BOGIE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-2832
Mailing Address - Country:US
Mailing Address - Phone:573-999-4925
Mailing Address - Fax:
Practice Address - Street 1:101 BOGIE HILLS DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-2832
Practice Address - Country:US
Practice Address - Phone:573-999-4925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018030950224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant