Provider Demographics
NPI:1417025289
Name:MARTIN, TRACY DALE (PT, ATC)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:DALE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6167
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-6167
Mailing Address - Country:US
Mailing Address - Phone:865-977-8007
Mailing Address - Fax:865-977-4072
Practice Address - Street 1:829 E LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5001
Practice Address - Country:US
Practice Address - Phone:865-977-8282
Practice Address - Fax:865-982-0143
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000002660225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist