Provider Demographics
NPI:1821241480
Name:BALTHAZOR, TRACY ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANN
Last Name:BALTHAZOR
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 1:3092 NOBLE CT
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-6211
Mailing Address - Country:US
Mailing Address - Phone:303-440-8175
Mailing Address - Fax:
Practice Address - Street 1:4145 NEVIS ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-6818
Practice Address - Country:US
Practice Address - Phone:303-928-9646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3322225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist