Provider Demographics
NPI: | 1568726081 |
---|---|
Name: | TUCKER, KATELIN RENEE (PT, DPT, CERT MDT) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | KATELIN |
Middle Name: | RENEE |
Last Name: | TUCKER |
Suffix: | |
Gender: | F |
Credentials: | PT, DPT, CERT MDT |
Other - Prefix: | |
Other - First Name: | KATELIN |
Other - Middle Name: | RENEE |
Other - Last Name: | SIEVERT |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | PT, DPT, CERT MDT |
Mailing Address - Street 1: | 683 BURMA RD |
Mailing Address - Street 2: | |
Mailing Address - City: | RIVERTON |
Mailing Address - State: | WY |
Mailing Address - Zip Code: | 82501-9763 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 763-232-1756 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 535 E MAIN ST STE D |
Practice Address - Street 2: | |
Practice Address - City: | LANDER |
Practice Address - State: | WY |
Practice Address - Zip Code: | 82520-3424 |
Practice Address - Country: | US |
Practice Address - Phone: | 307-335-3471 |
Practice Address - Fax: | 307-332-5388 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2012-06-28 |
Last Update Date: | 2022-11-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
225100000X | ||
WY | PT1743 | 2251X0800X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |