Provider Demographics
NPI:1659948784
Name:WILLIAMS, TRACIE (LMT)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-2246
Mailing Address - Country:US
Mailing Address - Phone:419-756-6111
Mailing Address - Fax:419-756-2549
Practice Address - Street 1:990 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2246
Practice Address - Country:US
Practice Address - Phone:419-756-6111
Practice Address - Fax:419-756-2549
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.019177225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist