Provider Demographics
NPI:1285038554
Name:PETTY, TRACIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:PETTY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 BROADWAY ST STE 312
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7895
Mailing Address - Country:US
Mailing Address - Phone:281-485-4818
Mailing Address - Fax:281-485-5446
Practice Address - Street 1:9330 BROADWAY ST STE 312
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-7895
Practice Address - Country:US
Practice Address - Phone:281-485-4818
Practice Address - Fax:281-485-5446
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1193573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist