Provider Demographics
NPI:1811418791
Name:THORSON, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:THORSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22369 HIGHWAY 60
Mailing Address - Street 2:
Mailing Address - City:WABASHA
Mailing Address - State:MN
Mailing Address - Zip Code:55981-2199
Mailing Address - Country:US
Mailing Address - Phone:715-791-9592
Mailing Address - Fax:
Practice Address - Street 1:507 W DOUGHTY ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1500
Practice Address - Country:US
Practice Address - Phone:651-345-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist