Provider Demographics
NPI:1578543971
Name:BAKER, TRACIE LYNN (MPT)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LYNN
Last Name:BAKER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:LYNN
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPT
Mailing Address - Street 1:121 BRIARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CRANBERRY TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:16066-4709
Mailing Address - Country:US
Mailing Address - Phone:724-776-3911
Mailing Address - Fax:
Practice Address - Street 1:121 BRIARWOOD LN
Practice Address - Street 2:
Practice Address - City:CRANBERRY TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:16066-4709
Practice Address - Country:US
Practice Address - Phone:724-776-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013716L225100000X
PADAPT000580225100000X
OHPT9363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1344514OtherHIGHMARK
PA7418394OtherAETNA
396677Medicare ID - Type Unspecified