Provider Demographics
NPI:1942555883
Name:BERNZOTT, TRACY ANN (LMT)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:ANN
Last Name:BERNZOTT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 704
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34423-0704
Mailing Address - Country:US
Mailing Address - Phone:352-795-0919
Mailing Address - Fax:
Practice Address - Street 1:9990 W FORT ISLAND TRL
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-5236
Practice Address - Country:US
Practice Address - Phone:352-795-0919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0007969225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist