Provider Demographics
NPI:1689763674
Name:SCHMIDT, TRACI D (PT)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:D
Last Name:SCHMIDT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:D
Other - Last Name:BOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1221 MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1745
Mailing Address - Country:US
Mailing Address - Phone:208-255-6693
Mailing Address - Fax:208-265-0875
Practice Address - Street 1:110 TIBBETTS DR
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-9812
Practice Address - Country:US
Practice Address - Phone:208-255-7337
Practice Address - Fax:208-561-9705
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1518225100000X
2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010137720OtherBLUE SHIELD
WA7122757Medicaid
ID806157500Medicaid
IDT7374OtherBLUE CROSS
MT3400170Medicaid
ID000010137720OtherBLUE SHIELD