Provider Demographics
NPI:1649487828
Name:CROUCH, TRACEYLIN SALES (MPT)
Entity type:Individual
Prefix:MRS
First Name:TRACEYLIN
Middle Name:SALES
Last Name:CROUCH
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 1:1615 KALAEPAA DR
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-3010
Mailing Address - Country:US
Mailing Address - Phone:808-990-2060
Mailing Address - Fax:
Practice Address - Street 1:1615 KALAEPAA DR
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-3010
Practice Address - Country:US
Practice Address - Phone:808-990-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT13902251X0800X
COPTL00103282251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic