Provider Demographics
NPI:1114278397
Name:HAACKER, TIMOTHY (DPT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:HAACKER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 E BENGAL BLVD
Mailing Address - Street 2:E302
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-7135
Mailing Address - Country:US
Mailing Address - Phone:262-721-7095
Mailing Address - Fax:
Practice Address - Street 1:1138 E WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2819
Practice Address - Country:US
Practice Address - Phone:801-581-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8225227-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist