Provider Demographics
NPI:1164815510
Name:EUSTICE, TRACY (PTA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:EUSTICE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 N BELMONT DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5234
Mailing Address - Country:US
Mailing Address - Phone:507-276-1650
Mailing Address - Fax:
Practice Address - Street 1:336 N BELMONT DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5234
Practice Address - Country:US
Practice Address - Phone:507-276-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA3372251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics