Provider Demographics
NPI:1851434955
Name:BLUM, TRACY L (PT)
Entity Type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:L
Last Name:BLUM
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 1:17 COASTAL OAK
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2126
Mailing Address - Country:US
Mailing Address - Phone:949-933-2586
Mailing Address - Fax:949-215-6935
Practice Address - Street 1:17 COASTAL OAK
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-2126
Practice Address - Country:US
Practice Address - Phone:949-933-2586
Practice Address - Fax:949-215-6935
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist