Provider Demographics
NPI:1093223182
Name:BROCKETT, TIM RAY
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:RAY
Last Name:BROCKETT
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 1:56 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4520
Mailing Address - Country:US
Mailing Address - Phone:440-812-2853
Mailing Address - Fax:
Practice Address - Street 1:56 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4520
Practice Address - Country:US
Practice Address - Phone:440-812-2853
Practice Address - Fax:931-707-9474
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLOTA16207224Z00000X
FLOT22381225X00000X
TN7758225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist