Healthcare Provider Details

I. General information

NPI: 1972467132
Provider Name (Legal Business Name): TRACY LEE REIDEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 SW UNEEDA PL
PORT SAINT LUCIE FL
34953-5487
US

IV. Provider business mailing address

244 SW UNEEDA PL
PORT SAINT LUCIE FL
34953-5487
US

V. Phone/Fax

Practice location:
  • Phone: 716-481-3390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number26579
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: