Provider Demographics
NPI:1417928342
Name:LOVETT, TRACY OLIVER (RPT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:OLIVER
Last Name:LOVETT
Suffix:
Gender:F
Credentials:RPT
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 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:706-802-1991
Mailing Address - Fax:706-802-1408
Practice Address - Street 1:101 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2501
Practice Address - Country:US
Practice Address - Phone:478-272-7494
Practice Address - Fax:478-272-2616
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000717615CMedicaid
GA000717615DMedicaid
GA000717615AMedicaid
GA000717615BMedicaid