Provider Demographics
NPI:1457457871
Name:CALVERT, TRACY JACKSON (MS, PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:JACKSON
Last Name:CALVERT
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 INNOVATION DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-8096
Mailing Address - Country:US
Mailing Address - Phone:724-343-4060
Mailing Address - Fax:724-343-4069
Practice Address - Street 1:1130 VALLEY FORGE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-2658
Practice Address - Country:US
Practice Address - Phone:610-917-0725
Practice Address - Fax:610-917-0573
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007283L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0516599000OtherINDEPENDENCE BLUE CROSS
PA234443OtherHEALTH AMER/HEALTH ASSUR
PAJA667629OtherHIGHMARK BLUE SHIELD
PA0516599000OtherINDEPENDENCE BLUE CROSS