Provider Demographics
NPI:1174207781
Name:PUCCIO, TARA K (PT)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:K
Last Name:PUCCIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1692 RELIANCE CIR
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:CO
Mailing Address - Zip Code:80027-4405
Mailing Address - Country:US
Mailing Address - Phone:303-917-1029
Mailing Address - Fax:
Practice Address - Street 1:2800 PALO PKWY
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1540
Practice Address - Country:US
Practice Address - Phone:303-440-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL0006049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist