Provider Demographics
NPI:1326246646
Name:HARRISONMADGE, TRACI TARA (COTAL)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:TARA
Last Name:HARRISONMADGE
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7902 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64138-1901
Mailing Address - Country:US
Mailing Address - Phone:816-337-2441
Mailing Address - Fax:
Practice Address - Street 1:7902 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64138-1901
Practice Address - Country:US
Practice Address - Phone:816-337-2441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006012245224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant