Provider Demographics
NPI:1619083953
Name:BATES, TRACY CONSTABLE (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:CONSTABLE
Last Name:BATES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 DENBY WAY
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-4321
Mailing Address - Country:US
Mailing Address - Phone:804-378-2227
Mailing Address - Fax:
Practice Address - Street 1:13700 ST FRANCIS BLVD
Practice Address - Street 2:STE 103
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-3222
Practice Address - Country:US
Practice Address - Phone:804-379-2414
Practice Address - Fax:804-379-2413
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005264225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0472640015Medicare NSC
VA012870W25Medicare PIN