Healthcare Provider Details

I. General information

NPI: 1154477966
Provider Name (Legal Business Name): TRACEY KIMBERLY SPEARS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26900 FRANKLIN RD
SOUTHFIELD MI
48034-5312
US

IV. Provider business mailing address

22627 STRAWBERRY CT 101
NOVI MI
48375-4676
US

V. Phone/Fax

Practice location:
  • Phone: 248-350-8070
  • Fax: 248-350-8078
Mailing address:
  • Phone: 313-433-7477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: