Provider Demographics
NPI:1720449556
Name:CLARK, TRACEY
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 MAIN ST
Mailing Address - Street 2:1200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-4327
Mailing Address - Country:US
Mailing Address - Phone:972-900-2708
Mailing Address - Fax:
Practice Address - Street 1:2201 MAIN ST
Practice Address - Street 2:#1200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-4327
Practice Address - Country:US
Practice Address - Phone:972-900-2708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225700000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX225700000XOtherMASSAGE THERAPY