Provider Demographics
NPI:1700806791
Name:RODRIGUEZ, TRACEY (MPT)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:RODRIGUEZ
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 1:1419 WEEPING WILLOW CT
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-4581
Mailing Address - Country:US
Mailing Address - Phone:732-431-2883
Mailing Address - Fax:
Practice Address - Street 1:222 SCHANCK RD
Practice Address - Street 2:SUITE 301
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-3068
Practice Address - Country:US
Practice Address - Phone:732-431-2883
Practice Address - Fax:732-431-2865
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA01140400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist