Provider Demographics
NPI:1174653760
Name:PORTO, TRACY (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:PORTO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 E BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:FARMERVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71241-3003
Mailing Address - Country:US
Mailing Address - Phone:318-368-9600
Mailing Address - Fax:318-368-9603
Practice Address - Street 1:207 E BAYOU ST
Practice Address - Street 2:
Practice Address - City:FARMERVILLE
Practice Address - State:LA
Practice Address - Zip Code:71241-3003
Practice Address - Country:US
Practice Address - Phone:318-368-9600
Practice Address - Fax:318-368-9603
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA211002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA211002OtherLICENSE