Provider Demographics
NPI:1609816610
Name:MERRILL, TRACEY A (PT, OCS, ATC-L)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:A
Last Name:MERRILL
Suffix:
Gender:F
Credentials:PT, OCS, ATC-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VALLEY ST
Mailing Address - Street 2:#1
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-4320
Mailing Address - Country:US
Mailing Address - Phone:207-799-8226
Mailing Address - Fax:
Practice Address - Street 1:161 OCEAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3623
Practice Address - Country:US
Practice Address - Phone:207-799-8226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME0155Medicare ID - Type Unspecified