Provider Demographics
NPI:1326170721
Name:DEWOLFE, TRACY MARIE (MPT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:DEWOLFE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:HOWARD LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55349-9587
Mailing Address - Country:US
Mailing Address - Phone:320-543-2913
Mailing Address - Fax:
Practice Address - Street 1:303 CATLIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1947
Practice Address - Country:US
Practice Address - Phone:763-684-3888
Practice Address - Fax:763-684-3884
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist