Provider Demographics
NPI:1205191269
Name:PUCKETT, COLTON JUDSON (PTA)
Entity Type:Individual
Prefix:MR
First Name:COLTON
Middle Name:JUDSON
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:395 COUNTY ROAD 3101
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75426-6905
Mailing Address - Country:US
Mailing Address - Phone:903-249-0386
Mailing Address - Fax:903-427-8256
Practice Address - Street 1:395 COUNTY ROAD 3101
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75426-6905
Practice Address - Country:US
Practice Address - Phone:903-249-0386
Practice Address - Fax:903-427-8256
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2080660225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant