Provider Demographics
NPI:1467759142
Name:KIMBALL, TRACY A (COTA/L)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:KIMBALL
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:ANNE
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA/L
Mailing Address - Street 1:651 MAURICE ST
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17404-1394
Mailing Address - Country:US
Mailing Address - Phone:877-312-6576
Mailing Address - Fax:814-506-8213
Practice Address - Street 1:651 MAURICE ST
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17404-1394
Practice Address - Country:US
Practice Address - Phone:717-433-5747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP006498224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant