Provider Demographics
NPI:1407196116
Name:FRY, TRACEY LYNNE (OTR/L)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNNE
Last Name:FRY
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 HICKS PIKE
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-5730
Mailing Address - Country:US
Mailing Address - Phone:859-235-0997
Mailing Address - Fax:
Practice Address - Street 1:3699 ALEXANDRIA PIKE STE D
Practice Address - Street 2:
Practice Address - City:COLD SPRING
Practice Address - State:KY
Practice Address - Zip Code:41076-1789
Practice Address - Country:US
Practice Address - Phone:859-572-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY133529225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY225X0000XOtherOCCUPATIONAL THERAPIST