Provider Demographics
NPI:1568707842
Name:PUCKETT, TIM JAMES (D,PT)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:JAMES
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:D,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 S WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4128
Mailing Address - Country:US
Mailing Address - Phone:928-649-9726
Mailing Address - Fax:928-634-2079
Practice Address - Street 1:480 S WILLARD ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4128
Practice Address - Country:US
Practice Address - Phone:928-649-9726
Practice Address - Fax:928-634-2079
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10101PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ10101PTOtherSTATE OF ARIZONA PHYSICAL THERAPY LICENSE NUMBER