Provider Demographics
NPI:1093735185
Name:WISE, TRACI L (ATC)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:L
Last Name:WISE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MS
Other - First Name:TRACI
Other - Middle Name:L
Other - Last Name:MCSWEEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATC
Mailing Address - Street 1:104 CARDINAL RD
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:GA
Mailing Address - Zip Code:31569-4318
Mailing Address - Country:US
Mailing Address - Phone:912-674-0682
Mailing Address - Fax:912-576-4906
Practice Address - Street 1:104 CARDINAL RD
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:GA
Practice Address - Zip Code:31569-4318
Practice Address - Country:US
Practice Address - Phone:912-576-2900
Practice Address - Fax:912-576-4906
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0011302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer