Provider Demographics
NPI:1205919198
Name:TRACY, ROBIN CATHERINE (PT, ATC)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:CATHERINE
Last Name:TRACY
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX I
Mailing Address - Street 2:
Mailing Address - City:PARK RIVER
Mailing Address - State:ND
Mailing Address - Zip Code:58270-0708
Mailing Address - Country:US
Mailing Address - Phone:701-284-4570
Mailing Address - Fax:701-284-4581
Practice Address - Street 1:1425 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4039
Practice Address - Country:US
Practice Address - Phone:701-746-8374
Practice Address - Fax:701-780-0885
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND137-942255A2300X
ND972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1013166OtherPREFERRED ONE GROUP # PT
ND54206Medicaid
ND50668Medicaid
MN7B137PAOtherBCBS MN PT
MN125177500Medicaid
ND12670OtherBCBS ND PT