Provider Demographics
NPI:1861688376
Name:CANTRELL, TRACI SUZANNE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:SUZANNE
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1230 S MISSOURI AVE
Mailing Address - Street 2:703
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-9174
Mailing Address - Country:US
Mailing Address - Phone:727-215-7197
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD
Practice Address - Street 2:240
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1047
Practice Address - Country:US
Practice Address - Phone:610-834-1122
Practice Address - Fax:610-834-7525
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant