Provider Demographics
NPI:1639573504
Name:TRACEY, SEAN CAMERON (PT)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:CAMERON
Last Name:TRACEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9650 S RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-9526
Mailing Address - Country:US
Mailing Address - Phone:419-360-7288
Mailing Address - Fax:
Practice Address - Street 1:555 ANTHONY WAYNE TRL
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43566-1516
Practice Address - Country:US
Practice Address - Phone:419-878-3901
Practice Address - Fax:419-878-6872
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH014943225100000X
MI5501016822225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist