Provider Demographics
NPI:1083600886
Name:TUCKER, DIANA (PTA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 DORSEY HALL DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-7766
Mailing Address - Country:US
Mailing Address - Phone:410-730-9851
Mailing Address - Fax:410-730-9855
Practice Address - Street 1:4801 DORSEY HALL DR
Practice Address - Street 2:SUITE 130
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-7766
Practice Address - Country:US
Practice Address - Phone:410-730-9851
Practice Address - Fax:410-730-9855
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2081225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant