Provider Demographics
NPI:1801956651
Name:BUCK, TAMARA L (PT)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:L
Last Name:BUCK
Suffix:
Gender:F
Credentials:PT
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 670207
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-0121
Mailing Address - Country:US
Mailing Address - Phone:770-517-2480
Mailing Address - Fax:770-592-9431
Practice Address - Street 1:2465 CANOPY GLN
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-1541
Practice Address - Country:US
Practice Address - Phone:770-517-2480
Practice Address - Fax:770-592-9431
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4710225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4710OtherPHYSICAL THERAPY LICENSE
GA10040347OtherAMERIGROUP
GA318310OtherWELLCARE