Provider Demographics
NPI:1134324114
Name:PURVIS, TRACI LYNN (OTRL)
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:LYNN
Last Name:PURVIS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1846
Mailing Address - Country:US
Mailing Address - Phone:502-639-0940
Mailing Address - Fax:502-456-2667
Practice Address - Street 1:4211 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1846
Practice Address - Country:US
Practice Address - Phone:502-639-0940
Practice Address - Fax:502-456-2667
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2744225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12084937OtherCAQH NUMBER
KY1362OtherFIRST STEPS BILLING NUMBE