Provider Demographics
NPI:1912496399
Name:DEWITT, TRACY (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DEWITT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 BERESFORD CREEK ST
Mailing Address - Street 2:
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492-7518
Mailing Address - Country:US
Mailing Address - Phone:843-327-7655
Mailing Address - Fax:
Practice Address - Street 1:1476 LONG GROVE DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7571
Practice Address - Country:US
Practice Address - Phone:843-216-3534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4430225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist