Provider Demographics
NPI:1841216074
Name:HOLTZMAN, TRACY S (PT)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:S
Last Name:HOLTZMAN
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 1:1 CHILDRENS PL
Mailing Address - Street 2:C B 8116
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1002
Mailing Address - Country:US
Mailing Address - Phone:314-454-6050
Mailing Address - Fax:314-454-4801
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:STE 11E10
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6050
Practice Address - Fax:314-454-4801
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO489255703Medicaid
MO489255703Medicaid
OTH0006Medicare UPIN
MO489255703Medicaid