Provider Demographics
NPI:1518533884
Name:HOOGSHAGEN, TRACY L (MT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:HOOGSHAGEN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 N 27TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783-3349
Mailing Address - Country:US
Mailing Address - Phone:605-644-9074
Mailing Address - Fax:605-722-0306
Practice Address - Street 1:311 N 27TH ST STE 1
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783-3349
Practice Address - Country:US
Practice Address - Phone:605-644-9074
Practice Address - Fax:605-722-0306
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT10695225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist