Provider Demographics
NPI:1295728541
Name:GARRETT, TRACY PAMELA (PT)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:PAMELA
Last Name:GARRETT
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 1:4569 WADITA KA WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33417-8014
Mailing Address - Country:US
Mailing Address - Phone:561-478-0964
Mailing Address - Fax:
Practice Address - Street 1:4569 WADITA KA WAY
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33417-8014
Practice Address - Country:US
Practice Address - Phone:561-478-0964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 5565225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888749700Medicaid
FL810591000Medicaid