Healthcare Provider Details

I. General information

NPI: 1023001344
Provider Name (Legal Business Name): THOMAS RUSSELL COOKSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CORPORATE PL SUITE 103
PEABODY MA
01960-3865
US

IV. Provider business mailing address

100 CORPORATE PL SUITE 103
PEABODY MA
01960-3865
US

V. Phone/Fax

Practice location:
  • Phone: 978-535-1213
  • Fax: 978-535-5510
Mailing address:
  • Phone: 978-535-1213
  • Fax: 978-535-5510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number8766
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: