Provider Demographics
NPI:1164677886
Name:HERON-MOORE, TRACY C (LMP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:C
Last Name:HERON-MOORE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1464
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-1464
Mailing Address - Country:US
Mailing Address - Phone:360-486-4446
Mailing Address - Fax:
Practice Address - Street 1:541 MCPHEE RD SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5015
Practice Address - Country:US
Practice Address - Phone:360-486-4446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-21
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00025347225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist