Provider Demographics
NPI:1942346945
Name:SMITH, TRACIE JEANNETTE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:JEANNETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SUMMERSET LN
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-2819
Mailing Address - Country:US
Mailing Address - Phone:636-931-0211
Mailing Address - Fax:
Practice Address - Street 1:10560 OLD OLIVE STREET RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-5916
Practice Address - Country:US
Practice Address - Phone:314-567-4707
Practice Address - Fax:314-567-4505
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1114090792OtherGROUP NPI NUMBER