Provider Demographics
NPI:1922118629
Name:BECKETT, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BECKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8444 TIBET BUTLER DR
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-5304
Mailing Address - Country:US
Mailing Address - Phone:919-303-1631
Mailing Address - Fax:
Practice Address - Street 1:1177 BLACKWOOD AVE
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4518
Practice Address - Country:US
Practice Address - Phone:407-292-0073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT7709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT7709OtherLICENSE #