Basic Information
| Provider Information | |||||||||
| NPI: | 1891069167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VINCENT | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10000 W 75TH ST | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662042209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138941910 | ||||||||
| FaxNumber: | 8779131174 | ||||||||
| Practice Location | |||||||||
| Address1: | 10000 W 75TH ST | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662042209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138941910 | ||||||||
| FaxNumber: | 8779131174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2012 | ||||||||
| LastUpdateDate: | 01/29/2013 | ||||||||
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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 | 225100000X | P13567 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251P0200X | P13567 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7212990 | 05 | NC | MEDICAID |