Provider Demographics
NPI:1841486099
Name:TEAGUE, TRACY EDWARD (PT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:EDWARD
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:14207 MERIDIAN E STE 100
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-2414
Practice Address - Country:US
Practice Address - Phone:253-770-1807
Practice Address - Fax:253-770-1985
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000058702251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPT00005870OtherPT LICENSE