Provider Demographics
NPI:1538510086
Name:EASTON, TRACY (LMT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:EASTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2627 VANNESS ST.
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-334-3254
Mailing Address - Fax:
Practice Address - Street 1:2627 VANNESS ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6847
Practice Address - Country:US
Practice Address - Phone:810-334-3254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501009149225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist