Provider Demographics
NPI:1922353218
Name:RENFROW, TRACY CARROLL (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:CARROLL
Last Name:RENFROW
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13615 BISCAYNE GROVE LN
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32735-9647
Mailing Address - Country:US
Mailing Address - Phone:352-205-9775
Mailing Address - Fax:
Practice Address - Street 1:5001 STATESMAN DR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2414
Practice Address - Country:US
Practice Address - Phone:800-788-4815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12609225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist