Provider Demographics
NPI:1780902452
Name:WALKER, TRACEY LEIGH (LMT)
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:LEIGH
Last Name:WALKER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 MARLON ST
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-9218
Mailing Address - Country:US
Mailing Address - Phone:541-231-4341
Mailing Address - Fax:
Practice Address - Street 1:230 SW 3RD ST
Practice Address - Street 2:SUITE 211
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-4692
Practice Address - Country:US
Practice Address - Phone:541-231-4341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10808172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist