Provider Demographics
NPI:1285843383
Name:PRICKETT, NATHAN ALAN (MPT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ALAN
Last Name:PRICKETT
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 W MARTINDALE RD
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:OH
Mailing Address - Zip Code:45322-3043
Mailing Address - Country:US
Mailing Address - Phone:937-572-9766
Mailing Address - Fax:
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-832-8982
Practice Address - Fax:937-832-8973
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH11350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist