Provider Demographics
NPI:1043894058
Name:SMITH, TRACEE LATASHIA (PT)
Entity Type:Individual
Prefix:
First Name:TRACEE
Middle Name:LATASHIA
Last Name:SMITH
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 1:6000 HILLANDALE DR STE 145
Mailing Address - Street 2:
Mailing Address - City:STONECREST
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4860
Mailing Address - Country:US
Mailing Address - Phone:678-418-8072
Mailing Address - Fax:678-518-0137
Practice Address - Street 1:6000 HILLANDALE DR STE 145
Practice Address - Street 2:
Practice Address - City:STONECREST
Practice Address - State:GA
Practice Address - Zip Code:30058-4860
Practice Address - Country:US
Practice Address - Phone:678-418-8072
Practice Address - Fax:678-518-0137
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACP004768T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist