Provider Demographics
NPI:1164819330
Name:HOUSTON, TRACY (ATC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:HOUSTON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13641 LOREN LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-8413
Mailing Address - Country:US
Mailing Address - Phone:479-422-0218
Mailing Address - Fax:
Practice Address - Street 1:500 COLE DR
Practice Address - Street 2:
Practice Address - City:PRAIRIE GROVE
Practice Address - State:AR
Practice Address - Zip Code:72753-2509
Practice Address - Country:US
Practice Address - Phone:479-846-4212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1101022782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer