Provider Demographics
NPI:1912238973
Name:BRACKETT, RONALD DAVID (PT)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:DAVID
Last Name:BRACKETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 FOREST LN STE A
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-2621
Mailing Address - Country:US
Mailing Address - Phone:864-722-0335
Mailing Address - Fax:800-305-7112
Practice Address - Street 1:313 MANUFACTURERS RD STE 215
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37405-3337
Practice Address - Country:US
Practice Address - Phone:423-254-5461
Practice Address - Fax:800-385-7439
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6273225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1517344Medicaid