Provider Demographics
NPI:1649289299
Name:WHITELEATHER, TRACY DAWN (PT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:DAWN
Last Name:WHITELEATHER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:DAWN
Other - Last Name:BEASEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 350034
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43635-0034
Mailing Address - Country:US
Mailing Address - Phone:260-420-4400
Mailing Address - Fax:260-420-4448
Practice Address - Street 1:3217 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5427
Practice Address - Country:US
Practice Address - Phone:260-420-4400
Practice Address - Fax:260-420-4448
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006313A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200492840Medicaid
INCG1609Medicare PIN
IN145240CMedicare PIN