Provider Demographics
NPI:1275287443
Name:WALCK, TRACY (OT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:WALCK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3331 SUMMIT BLVD APT 172
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-4331
Mailing Address - Country:US
Mailing Address - Phone:850-741-6715
Mailing Address - Fax:850-240-0489
Practice Address - Street 1:101 MCABEE CT
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4756
Practice Address - Country:US
Practice Address - Phone:850-748-2841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT22453225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist