Provider Demographics
NPI:1326161977
Name:VAN VUGHT, TRACY M (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:VAN VUGHT
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 1:80 STONINGTON RD
Mailing Address - Street 2:SUITE A3
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2965
Mailing Address - Country:US
Mailing Address - Phone:860-536-1699
Mailing Address - Fax:
Practice Address - Street 1:80 STONINGTON RD
Practice Address - Street 2:SUITE A3
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2965
Practice Address - Country:US
Practice Address - Phone:860-536-1699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist