Provider Demographics
NPI:1215590062
Name:GRANT, TRACIE RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:RENEE
Last Name:GRANT
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 1:4310 LAKEFIELD MEWS DR APT A
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23231-4159
Mailing Address - Country:US
Mailing Address - Phone:804-397-8736
Mailing Address - Fax:
Practice Address - Street 1:1150 MARSH STREET
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560
Practice Address - Country:US
Practice Address - Phone:804-434-4308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604644225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant