Healthcare Provider Details

I. General information

NPI: 1386259307
Provider Name (Legal Business Name): KEVIN T TUCKER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

881 NEW HARWINTON RD
TORRINGTON CT
06790-5948
US

IV. Provider business mailing address

465 WOLCOTT RD
WOLCOTT CT
06716-2613
US

V. Phone/Fax

Practice location:
  • Phone: 860-482-0600
  • Fax: 860-482-0601
Mailing address:
  • Phone: 203-879-0107
  • Fax: 203-879-0206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12759
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: