Provider Demographics
NPI:1235993916
Name:COLEMAN, TRACY (MTRS, CTRS)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:MTRS, CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3880 S 2990 W
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-2066
Mailing Address - Country:US
Mailing Address - Phone:385-405-9590
Mailing Address - Fax:
Practice Address - Street 1:3855 S 700 E
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84106-1157
Practice Address - Country:US
Practice Address - Phone:385-405-9590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT346459-4001225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist