Healthcare Provider Details

I. General information

NPI: 1093796062
Provider Name (Legal Business Name): TARA R HUTTO D.P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 12/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 VILLAGE SQUARE DR
PADUCAH KY
42001-9060
US

IV. Provider business mailing address

PO BOX 7208
PADUCAH KY
42002-7208
US

V. Phone/Fax

Practice location:
  • Phone: 270-415-9575
  • Fax: 270-415-9576
Mailing address:
  • Phone: 270-415-9575
  • Fax: 270-415-9576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT002077
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: