Provider Demographics
NPI:1235110131
Name:SMITH, TRACY ALEXANDRA (DPT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ALEXANDRA
Last Name:SMITH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 BLACKTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-5604
Mailing Address - Country:US
Mailing Address - Phone:619-729-9993
Mailing Address - Fax:
Practice Address - Street 1:353 E PARK AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3988
Practice Address - Country:US
Practice Address - Phone:323-893-5844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist