Provider Demographics
NPI:1629532197
Name:LUCY-SPEIDEL, TRISTAN ZACHARY
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:ZACHARY
Last Name:LUCY-SPEIDEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 PINE TREE LN
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:VA
Mailing Address - Zip Code:22652-3221
Mailing Address - Country:US
Mailing Address - Phone:540-933-6399
Mailing Address - Fax:
Practice Address - Street 1:187 PINE TREE LN
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:VA
Practice Address - Zip Code:22652-3221
Practice Address - Country:US
Practice Address - Phone:540-933-6399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VIT644352052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer