=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205347887
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BECKY TUCCI DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2017
-----------------------------------------------------
Last Update Date | 03/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1293 BROAD ST
-----------------------------------------------------
City | BLOOMFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07003-3060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-707-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 237 KINGSLAND AVE UNIT 2
-----------------------------------------------------
City | LYNDHURST
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07071-2608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-750-9292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA01745000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------