Provider Demographics
NPI:1689448862
Name:STEWART, TRACI D (LMT)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:D
Last Name:STEWART
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:PO BOX 26483
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-6483
Mailing Address - Country:US
Mailing Address - Phone:904-444-7286
Mailing Address - Fax:
Practice Address - Street 1:12058 SAN JOSE BLVD # 802-3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8666
Practice Address - Country:US
Practice Address - Phone:904-444-7286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA69978225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist