Provider Demographics
NPI:1093223182
Name:BROCKETT, TIMOTHY RAY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RAY
Last Name:BROCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 PEARSON ST
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33974-0428
Mailing Address - Country:US
Mailing Address - Phone:440-812-2853
Mailing Address - Fax:
Practice Address - Street 1:149 PEARSON ST
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33974-0428
Practice Address - Country:US
Practice Address - Phone:440-812-2853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA16207224Z00000X
FLOT22381225X00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist