Provider Demographics
NPI:1326653676
Name:DIVELEY, TRACI ANNETTE (PTA)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:ANNETTE
Last Name:DIVELEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 SUMMIT ARBOR DR APT 103
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3381
Mailing Address - Country:US
Mailing Address - Phone:309-216-3591
Mailing Address - Fax:
Practice Address - Street 1:10810 SANDY OAK LN
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8386
Practice Address - Country:US
Practice Address - Phone:919-846-7147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.001168225200000X
NCA7261225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant