Healthcare Provider Details

I. General information

NPI: 1497241319
Provider Name (Legal Business Name): BRENDA TRACY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 17TH ST NW STE 10
WASHINGTON DC
20010-2135
US

IV. Provider business mailing address

2306 GLENMORE TER
ROCKVILLE MD
20850-3034
US

V. Phone/Fax

Practice location:
  • Phone: 202-436-1279
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT2397
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: