Provider Demographics
NPI:1518202738
Name:MYERS, TRACI ROBERTA
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:ROBERTA
Last Name:MYERS
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 1:2240 N 225 E UNIT 53
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-2589
Mailing Address - Country:US
Mailing Address - Phone:406-788-2032
Mailing Address - Fax:
Practice Address - Street 1:400 E 5350 S
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6931
Practice Address - Country:US
Practice Address - Phone:801-479-9855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2357225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant