Provider Demographics
NPI:1811958879
Name:BUCK, MITZI (DPT)
Entity type:Individual
Prefix:MRS
First Name:MITZI
Middle Name:
Last Name:BUCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8602 WESTOWN PARKWAY
Mailing Address - Street 2:#1701
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266
Mailing Address - Country:US
Mailing Address - Phone:515-987-6747
Mailing Address - Fax:
Practice Address - Street 1:1050 E ARMY POST ROAD
Practice Address - Street 2:SUITE E & F
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315
Practice Address - Country:US
Practice Address - Phone:515-953-5817
Practice Address - Fax:515-953-1085
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03827225100000X
UT49201552401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA03827OtherSTATE LICENSE
IA04285OtherBCBS
IA0665737Medicaid
UT49201552401OtherSTATE LICENSE
IA0665737Medicaid