Provider Demographics
NPI:1790783785
Name:LAW, TRACY M (MPT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:LAW
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E LAMAR ST
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-3632
Mailing Address - Country:US
Mailing Address - Phone:229-924-9595
Mailing Address - Fax:229-924-9540
Practice Address - Street 1:205 E LAMAR ST
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3632
Practice Address - Country:US
Practice Address - Phone:229-924-9595
Practice Address - Fax:229-924-9540
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007303225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA373629458AMedicaid
GA373629458BMedicaid
GA373629458BMedicaid