Provider Demographics
NPI:1487644605
Name:STURDEVANT, TRACY L (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:STURDEVANT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-1206
Mailing Address - Country:US
Mailing Address - Phone:330-399-2221
Mailing Address - Fax:330-394-0122
Practice Address - Street 1:950 YOUNGSTOWN WARREN RD
Practice Address - Street 2:SUITE C
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-4644
Practice Address - Country:US
Practice Address - Phone:330-652-2403
Practice Address - Fax:330-652-2409
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-6124225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0222253Medicaid
OH2559020Medicaid
OH2559020Medicaid