Provider Demographics
NPI:1851000343
Name:IGLESIAS, TRACY SUE
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:SUE
Last Name:IGLESIAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 TIMBERLAKE CV NE
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30121-5289
Mailing Address - Country:US
Mailing Address - Phone:404-324-7534
Mailing Address - Fax:
Practice Address - Street 1:3126 CEDARTOWN HWY SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3773
Practice Address - Country:US
Practice Address - Phone:706-295-0014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001976225200000X
CT1976225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant