Basic Information
| Provider Information | |||||||||
| NPI: | 1104809052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARREY | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LYN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | PETRI | ||||||||
| OtherFirstName: | TRACEY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11481 SW HALL BLVD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5034431402 | ||||||||
| Practice Location | |||||||||
| Address1: | 1271 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532123360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149789100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 08/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 4900 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 269616 | 05 | OR | MEDICAID |