Provider Demographics
NPI:1518419001
Name:SMITH, TRACEY LEE (COTA/L)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4603 TIMBERWALK CT
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-6746
Mailing Address - Country:US
Mailing Address - Phone:703-864-6695
Mailing Address - Fax:
Practice Address - Street 1:4603 TIMBERWALK CT
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-6746
Practice Address - Country:US
Practice Address - Phone:703-864-6695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY136195224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant