Provider Demographics
NPI:1174824445
Name:RUDE, TRACY DAWN (CMT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:DAWN
Last Name:RUDE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3065 165TH LN NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-5107
Mailing Address - Country:US
Mailing Address - Phone:612-275-2761
Mailing Address - Fax:
Practice Address - Street 1:1061 109TH AVE NE
Practice Address - Street 2:SUITE D
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-3846
Practice Address - Country:US
Practice Address - Phone:763-208-4562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist