Provider Demographics
NPI:1083939342
Name:SWAN, TRACEY J
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:J
Last Name:SWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WOODCHASE PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4113
Mailing Address - Country:US
Mailing Address - Phone:601-924-7043
Mailing Address - Fax:601-924-8633
Practice Address - Street 1:102 WOODCHASE PARK DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4113
Practice Address - Country:US
Practice Address - Phone:601-924-7043
Practice Address - Fax:601-924-8633
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT0153225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist