Provider Demographics
NPI:1194729459
Name:TUCKEY, BRIAN KEITH (PT, OCS, JSCCI)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:TUCKEY
Suffix:
Gender:M
Credentials:PT, OCS, JSCCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 THOMAS JOHNSON DRIVE
Mailing Address - Street 2:SUITE L
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-5125
Mailing Address - Country:US
Mailing Address - Phone:301-698-9956
Mailing Address - Fax:301-698-9957
Practice Address - Street 1:75 THOMAS JOHNSON DRIVE
Practice Address - Street 2:SUITE L
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-5125
Practice Address - Country:US
Practice Address - Phone:301-698-9956
Practice Address - Fax:301-698-9957
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD473137OtherMAMSI
MD52780008OtherCAREFIRST OF MARYLAND
MD1180364OtherUNITED HEALTHCARE
MD1180364OtherUNITED HEALTHCARE