Provider Demographics
NPI:1114385366
Name:BURNS, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BURNS
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 1:500 FAIWAY DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441
Mailing Address - Country:US
Mailing Address - Phone:888-880-9270
Mailing Address - Fax:
Practice Address - Street 1:300 COLONIAL CENTER PKWY
Practice Address - Street 2:STE100N
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4899
Practice Address - Country:US
Practice Address - Phone:954-603-7885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA222Q00000X222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist