Provider Demographics
NPI:1275656050
Name:MILLER, TRACY J
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:J
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E BALTIMORE AVE
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3507
Mailing Address - Country:US
Mailing Address - Phone:610-892-8767
Mailing Address - Fax:
Practice Address - Street 1:311 E BALTIMORE AVE
Practice Address - Street 2:SUITE 100A
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3507
Practice Address - Country:US
Practice Address - Phone:610-892-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA218559225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist