MEDICARE: TRACY WEATHERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275009227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY WEATHERS

Provider Business Mailing Address
First Line	:	8527 FRANKLIN COVE WAY APT G
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46239-2262
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 E MARKET ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46204-3250
Country	:	US
Telephone Number	:	317-455-1634
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2018
Last Update Date	:	02/16/2019

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Directions to “ TRACY WEATHERS ” Practice Location

Language	Start Address	Practice Location

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