Healthcare Provider Details

I. General information

NPI: 1366654261
Provider Name (Legal Business Name): TRACY LYNN ANGUS OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 09/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7243 US HIGHWAY 301 S
RIVERVIEW FL
33578-8399
US

IV. Provider business mailing address

12208 LANGSHAW DR
THONOTOSASSA FL
33592-2732
US

V. Phone/Fax

Practice location:
  • Phone: 813-663-9828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT11118
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: