Provider Demographics
NPI:1750504965
Name:MAR, TRACY H (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:H
Last Name:MAR
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 1:918A DEWING AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4223
Mailing Address - Country:US
Mailing Address - Phone:510-301-0147
Mailing Address - Fax:866-541-2651
Practice Address - Street 1:815 STEWART DR
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94085-4514
Practice Address - Country:US
Practice Address - Phone:408-737-2335
Practice Address - Fax:866-541-2651
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist