Provider Demographics
NPI:1770676678
Name:TRACY, LORI JEAN (PT, MS)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:JEAN
Last Name:TRACY
Suffix:
Gender:F
Credentials:PT, MS
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:JEAN
Other - Last Name:VETO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, MS
Mailing Address - Street 1:1237 SAINT ALBANS LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1979
Mailing Address - Country:US
Mailing Address - Phone:910-459-2589
Mailing Address - Fax:
Practice Address - Street 1:1200 LEXINGTON GREEN LN
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1013
Practice Address - Country:US
Practice Address - Phone:407-322-3442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4857225100000X
FL38948225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC078KXOtherBLUE CROSS BLUE SHIELD NC
NC7283677Medicaid
NC7283677Medicaid