Provider Demographics
NPI:1740330562
Name:NUCUM, MATHERESA MAGALONG (PT)
Entity type:Individual
Prefix:
First Name:MATHERESA
Middle Name:MAGALONG
Last Name:NUCUM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MAGALONG
Other - Last Name:NUCUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:1820 MULBERRY CV
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-5535
Mailing Address - Country:US
Mailing Address - Phone:731-642-3317
Mailing Address - Fax:
Practice Address - Street 1:175 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-1636
Practice Address - Country:US
Practice Address - Phone:731-352-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT3937225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist