Provider Demographics
NPI:1922244367
Name:TRACY, CARISSA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:MARIE
Last Name:TRACY
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 1:8031 CANTURA MLS
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-3267
Mailing Address - Country:US
Mailing Address - Phone:210-595-6438
Mailing Address - Fax:
Practice Address - Street 1:1248 AUSTIN HWY STE 210
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4867
Practice Address - Country:US
Practice Address - Phone:210-646-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1189650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist