Provider Demographics
NPI:1275277709
Name:STEWART, TRACY (MT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-1552
Mailing Address - Country:US
Mailing Address - Phone:970-978-4392
Mailing Address - Fax:
Practice Address - Street 1:3820 W 10TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-1552
Practice Address - Country:US
Practice Address - Phone:970-978-4392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO.0024752225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist