Provider Demographics
NPI:1336142744
Name:PRICKETT, DENNIS L (PT)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:L
Last Name:PRICKETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 COMMERCE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8247
Mailing Address - Country:US
Mailing Address - Phone:575-525-2450
Mailing Address - Fax:575-522-9075
Practice Address - Street 1:1115 COMMERCE DR
Practice Address - Street 2:SUITE C
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:575-525-2450
Practice Address - Fax:575-522-9075
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1147225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK8214Medicaid
S58863Medicare UPIN
NMK8214Medicaid