Provider Demographics
NPI:1912341546
Name:LUNDGREN, TRACY LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 GLACIER MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-8324
Mailing Address - Country:US
Mailing Address - Phone:406-599-6781
Mailing Address - Fax:
Practice Address - Street 1:1221 WEST DURSTON RD.
Practice Address - Street 2:GALLATIN REST HOME
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718
Practice Address - Country:US
Practice Address - Phone:406-582-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PTA-LIC-4401225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant