Provider Demographics
NPI:1881876761
Name:WILSON, TRACY MARIE
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1932 STARDUST DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-1643
Mailing Address - Country:US
Mailing Address - Phone:727-236-0097
Mailing Address - Fax:
Practice Address - Street 1:1485 INTERNATIONAL PKWY
Practice Address - Street 2:SUITES 2051
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5303
Practice Address - Country:US
Practice Address - Phone:800-798-6035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11778225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist