Provider Demographics
NPI:1295767119
Name:MILLER, TRACY MARIE (PTA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:MARIE
Other - Last Name:WINSLOW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:510 TOWNE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1331
Mailing Address - Country:US
Mailing Address - Phone:315-637-4747
Mailing Address - Fax:315-637-6711
Practice Address - Street 1:510 TOWNE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1331
Practice Address - Country:US
Practice Address - Phone:315-637-4747
Practice Address - Fax:315-637-6711
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006022-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant