Provider Demographics
NPI:1225223589
Name:PUCKETT, CAROLYN KIM (PT)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:KIM
Last Name:PUCKETT
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 1:685 MAIN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-3562
Mailing Address - Country:US
Mailing Address - Phone:727-365-8838
Mailing Address - Fax:
Practice Address - Street 1:800 TARPON WOODS BLVD., SUITE F1
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685
Practice Address - Country:US
Practice Address - Phone:727-365-8838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 23951225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist