Provider Demographics
NPI:1740810993
Name:HEATHMAN, TRACY LEE
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:HEATHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-4243
Mailing Address - Country:US
Mailing Address - Phone:830-998-8585
Mailing Address - Fax:
Practice Address - Street 1:811 W CEDAR ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4243
Practice Address - Country:US
Practice Address - Phone:830-998-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKV084244597106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician