Basic Information
| Provider Information | |||||||||
| NPI: | 1861688376 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANTRELL | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | SUZANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1230 S MISSOURI AVE | ||||||||
| Address2: | 703 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337569174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272157197 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2250 HICKORY RD | ||||||||
| Address2: | 240 | ||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194621047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108341122 | ||||||||
| FaxNumber: | 6108347525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2007 | ||||||||
| LastUpdateDate: | 09/18/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA 20600 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.