Healthcare Provider Details

I. General information

NPI: 1154231314
Provider Name (Legal Business Name): TYLER JAMES BUCKLEY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46520 COUNTY ROAD 48
SOUTHOLD NY
11971-5040
US

IV. Provider business mailing address

25 WINDCREST DR
MANORVILLE NY
11949-2922
US

V. Phone/Fax

Practice location:
  • Phone: 631-765-9389
  • Fax:
Mailing address:
  • Phone: 631-375-4847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number056307
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: