Provider Demographics
NPI:1720690647
Name:PINCKNEY, TRACEY (MT007125)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:PINCKNEY
Suffix:
Gender:F
Credentials:MT007125
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4377 CHESTNUT LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4564
Mailing Address - Country:US
Mailing Address - Phone:404-333-5431
Mailing Address - Fax:
Practice Address - Street 1:149 S MCDONOUGH ST STE 280
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3693
Practice Address - Country:US
Practice Address - Phone:404-333-5431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT007125225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist