Healthcare Provider Details

I. General information

NPI: 1578810396
Provider Name (Legal Business Name): TRACY LYNN HERRMANN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2012
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 S 4TH ST
LOUISVILLE KY
40202-2407
US

IV. Provider business mailing address

1922 DREXEL HILL CT
SAINT LOUIS MO
63131-3647
US

V. Phone/Fax

Practice location:
  • Phone: 314-822-6285
  • Fax:
Mailing address:
  • Phone: 314-650-4958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberR1109
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: