Healthcare Provider Details

I. General information

NPI: 1154117745
Provider Name (Legal Business Name): BENJAMIN STEVEN TUCKER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2025
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 S PARK ST
DEER PARK WA
99006-7025
US

IV. Provider business mailing address

2424 INDIAN RIDGE RD
CHEWELAH WA
99109-9501
US

V. Phone/Fax

Practice location:
  • Phone: 509-276-8811
  • Fax:
Mailing address:
  • Phone: 509-831-8356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60569409
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: