Provider Demographics
NPI:1659392322
Name:HARRIS, TRACEY LIN (LPT)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LIN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 L PENNY LANE
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557
Mailing Address - Country:US
Mailing Address - Phone:252-240-7466
Mailing Address - Fax:
Practice Address - Street 1:534 N 35TH ST
Practice Address - Street 2:STE D
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-3182
Practice Address - Country:US
Practice Address - Phone:252-726-1802
Practice Address - Fax:252-726-1805
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6096225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC079PROtherBLUE CROSS BLUE SHIELD
2506423Medicare ID - Type Unspecified