Healthcare Provider Details

I. General information

NPI: 1104076587
Provider Name (Legal Business Name): TRACEY RENEE DUMPHY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 FLORIDA AVE S STE. 6
ROCKLEDGE FL
32955-2152
US

IV. Provider business mailing address

127 RIDGEMONT CIR SE
PALM BAY FL
32909-2318
US

V. Phone/Fax

Practice location:
  • Phone: 321-634-3688
  • Fax: 321-504-0955
Mailing address:
  • Phone: 321-327-4919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 13317
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: