Healthcare Provider Details

I. General information

NPI: 1801043971
Provider Name (Legal Business Name): TRACY MEDLIN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 STILESBORO RD NW SUITE 430
KENNESAW GA
30152-7744
US

IV. Provider business mailing address

5150 STILESBORO RD NW STE 210
KENNESAW GA
30152-7742
US

V. Phone/Fax

Practice location:
  • Phone: 770-218-2300
  • Fax: 770-218-2201
Mailing address:
  • Phone: 404-384-3650
  • Fax: 786-573-4809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT004265
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT004265
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: