Provider Demographics
NPI:1689747420
Name:BLACKMORE, TRACEY (PT)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:BLACKMORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6437 RUCKER RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4885
Mailing Address - Country:US
Mailing Address - Phone:317-405-9016
Mailing Address - Fax:
Practice Address - Street 1:8820 ANCHOR BAY CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-8210
Practice Address - Country:US
Practice Address - Phone:317-826-1853
Practice Address - Fax:317-826-1938
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007577A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200672050Medicaid