Provider Demographics
NPI:1811992514
Name:GENECCO, TIMOTHY DAVID (MSPT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DAVID
Last Name:GENECCO
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WIANNO WAY
Mailing Address - Street 2:
Mailing Address - City:SCITUATE
Mailing Address - State:MA
Mailing Address - Zip Code:02066-1520
Mailing Address - Country:US
Mailing Address - Phone:561-373-6308
Mailing Address - Fax:866-757-9692
Practice Address - Street 1:56 NEW DRIFTWAY
Practice Address - Street 2:
Practice Address - City:SCITUATE
Practice Address - State:MA
Practice Address - Zip Code:02066-4533
Practice Address - Country:US
Practice Address - Phone:781-544-3434
Practice Address - Fax:781-544-3946
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT12379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY5506ZMedicare ID - Type Unspecified