Provider Demographics
NPI:1508622986
Name:SOUZA, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SOUZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 ROGERS AVE STE E
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2986
Mailing Address - Country:US
Mailing Address - Phone:479-217-1240
Mailing Address - Fax:
Practice Address - Street 1:3401 ROGERS AVE STE E
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2986
Practice Address - Country:US
Practice Address - Phone:479-217-1240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR9393225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist