Provider Demographics
NPI:1851855746
Name:DAVIS, TRACY KYLE (OTA/L)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:KYLE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 STEWART ST SW
Mailing Address - Street 2:
Mailing Address - City:HARTSELLE
Mailing Address - State:AL
Mailing Address - Zip Code:35640-2920
Mailing Address - Country:US
Mailing Address - Phone:256-754-4456
Mailing Address - Fax:
Practice Address - Street 1:213 WILSON MANN RD
Practice Address - Street 2:
Practice Address - City:OWENS CROSS ROADS
Practice Address - State:AL
Practice Address - Zip Code:35763-8606
Practice Address - Country:US
Practice Address - Phone:256-725-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3391224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant