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
StateLicense IDTaxonomies
225100000X
WYPT17432251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist