Provider Demographics
NPI:1952789539
Name:BAKER, TRACIE LAUREN (LMT)
Entity Type:Individual
Prefix:MISS
First Name:TRACIE
Middle Name:LAUREN
Last Name:BAKER
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 1:558 INTERCHANGE RD
Mailing Address - Street 2:
Mailing Address - City:KRESGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18333-7721
Mailing Address - Country:US
Mailing Address - Phone:570-688-7273
Mailing Address - Fax:
Practice Address - Street 1:5620 EAST TEXAS RD
Practice Address - Street 2:
Practice Address - City:EAST TEXAS (MACUNGIE)
Practice Address - State:PA
Practice Address - Zip Code:18046
Practice Address - Country:US
Practice Address - Phone:610-398-7556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG003337225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist