Provider Demographics
NPI:1457853962
Name:KING, TRACIE LYNN (PTA)
Entity Type:Individual
Prefix:MS
First Name:TRACIE
Middle Name:LYNN
Last Name:KING
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:892 LONDON LANE APT 653
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142
Mailing Address - Country:US
Mailing Address - Phone:574-993-2415
Mailing Address - Fax:
Practice Address - Street 1:500 N CAPITOL AVE UNIT A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204
Practice Address - Country:US
Practice Address - Phone:317-983-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
06005656A225200000X
IN06005656A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty