Provider Demographics
NPI:1548570823
Name:BLAIR, TRACI LEE (PT)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LEE
Last Name:BLAIR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10464 PAMPLONA ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5597
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4600 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1210
Practice Address - Country:US
Practice Address - Phone:505-727-4628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist