Healthcare Provider Details

I. General information

NPI: 1548835531
Provider Name (Legal Business Name): TRACY WHITWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2021
Last Update Date: 05/23/2021
Certification Date: 05/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 E LINWOOD BLVD
KANSAS CITY MO
64128-2226
US

IV. Provider business mailing address

7003 S BUCKNER TARSNEY RD
OAK GROVE MO
64075-9770
US

V. Phone/Fax

Practice location:
  • Phone: 816-922-2740
  • Fax:
Mailing address:
  • Phone: 816-806-7133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number117154
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: