Provider Demographics
NPI:1659610194
Name:BAUM, TRACY JOYCE (LMP)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:JOYCE
Last Name:BAUM
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-5337
Mailing Address - Country:US
Mailing Address - Phone:360-584-0697
Mailing Address - Fax:
Practice Address - Street 1:145 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3037
Practice Address - Country:US
Practice Address - Phone:360-748-1580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60271102225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist