Provider Demographics
NPI:1710210729
Name:TUCKER, TRUDI RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:TRUDI
Middle Name:RENEE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 FANNIN DR
Mailing Address - Street 2:
Mailing Address - City:TULIA
Mailing Address - State:TX
Mailing Address - Zip Code:79088-1405
Mailing Address - Country:US
Mailing Address - Phone:806-994-0182
Mailing Address - Fax:806-994-9090
Practice Address - Street 1:67 FANNIN DR.
Practice Address - Street 2:
Practice Address - City:TULIA
Practice Address - State:TX
Practice Address - Zip Code:79088
Practice Address - Country:US
Practice Address - Phone:806-994-0182
Practice Address - Fax:806-994-9090
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2040574225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant