Healthcare Provider Details

I. General information

NPI: 1922377159
Provider Name (Legal Business Name): TARA LEE COCKE P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 HILLCREST DR SUITE 1
WACO TX
76708-3157
US

IV. Provider business mailing address

3500 HILLCREST DR. STE. 1
WACO TX
76708-3144
US

V. Phone/Fax

Practice location:
  • Phone: 888-624-6882
  • Fax: 888-882-4498
Mailing address:
  • Phone: 888-624-6882
  • Fax: 888-882-4498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1212341
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: