Provider Demographics
NPI:1568964369
Name:AYERS, TRACY ELIZABETH
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ELIZABETH
Last Name:AYERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:ELIZABETH
Other - Last Name:METRAILER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:11435 VENICE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-4028
Mailing Address - Country:US
Mailing Address - Phone:310-869-5842
Mailing Address - Fax:
Practice Address - Street 1:11435 VENICE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-4028
Practice Address - Country:US
Practice Address - Phone:310-869-5842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABOC2439062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABOC243906OtherBOARD OF CERTIFICATON