Provider Demographics
NPI:1417667684
Name:DANIELS, TRACEY ROCHELLE (COTA, LVN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:ROCHELLE
Last Name:DANIELS
Suffix:
Gender:F
Credentials:COTA, LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 SPENCER LN
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-6667
Mailing Address - Country:US
Mailing Address - Phone:903-330-1470
Mailing Address - Fax:
Practice Address - Street 1:16044 COUNTY ROAD 165
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-7302
Practice Address - Country:US
Practice Address - Phone:903-526-5599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT214067225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist