Provider Demographics
NPI:1003391038
Name:LATTIN, TRACY MARIE (PT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:LATTIN
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 1:3666 E BRIGHTON POINT DR
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-5555
Mailing Address - Country:US
Mailing Address - Phone:214-850-4879
Mailing Address - Fax:
Practice Address - Street 1:3666 E BRIGHTON POINT DR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-5555
Practice Address - Country:US
Practice Address - Phone:214-850-4879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT121369-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT121369-2401OtherHOME HEALTH