Provider Demographics
NPI:1275573511
Name:CAMPBELL, TRACY LEE (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 MILLPOND RD
Mailing Address - Street 2:STE A
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-6273
Mailing Address - Country:US
Mailing Address - Phone:219-707-5470
Mailing Address - Fax:219-707-5413
Practice Address - Street 1:970 MILLPOND RD STE A
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-6273
Practice Address - Country:US
Practice Address - Phone:219-241-0159
Practice Address - Fax:855-721-3101
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008269A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN874640NMedicare PIN
IN189890GMedicare UPIN