Provider Demographics
NPI:1639145154
Name:KNICKERBOCKER, JOEL C (RPT)
Entity Type:Individual
Prefix:MR
First Name:JOEL
Middle Name:C
Last Name:KNICKERBOCKER
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1001
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33526-1001
Mailing Address - Country:US
Mailing Address - Phone:352-521-0002
Mailing Address - Fax:352-521-5958
Practice Address - Street 1:37104 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-5911
Practice Address - Country:US
Practice Address - Phone:352-521-0002
Practice Address - Fax:352-521-5958
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0003564225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3564OtherLICENSE NUMBER
FL3564OtherLICENSE NUMBER