Provider Demographics
NPI:1649311192
Name:WILLIAMS, TRACEY (MPT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14090 HG TRUEMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:SOLOMONS
Mailing Address - State:MD
Mailing Address - Zip Code:20688
Mailing Address - Country:US
Mailing Address - Phone:410-394-2838
Mailing Address - Fax:410-326-5369
Practice Address - Street 1:14090 HG TRUEMAN ROAD
Practice Address - Street 2:
Practice Address - City:SOLOMONS
Practice Address - State:MD
Practice Address - Zip Code:20688
Practice Address - Country:US
Practice Address - Phone:410-394-2838
Practice Address - Fax:410-326-5369
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19598174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD606MMedicare ID - Type Unspecified