Provider Demographics
NPI:1295046282
Name:GANNON, TRACY ELIZABETH (MSPT)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:ELIZABETH
Last Name:GANNON
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HARTSHORN ROAD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906
Mailing Address - Country:US
Mailing Address - Phone:401-885-0069
Mailing Address - Fax:401-885-0071
Practice Address - Street 1:5600 POST ROAD
Practice Address - Street 2:SUITE 116
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818
Practice Address - Country:US
Practice Address - Phone:401-885-0069
Practice Address - Fax:401-885-0071
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01111225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist