Healthcare Provider Details

I. General information

NPI: 1679480982
Provider Name (Legal Business Name): KORTNEY TRACE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MCKINLEY AVE NW
CANTON OH
44702-1717
US

IV. Provider business mailing address

5960 ELMDALE ST NW
CANTON OH
44718-1122
US

V. Phone/Fax

Practice location:
  • Phone: 330-438-2500
  • Fax:
Mailing address:
  • Phone: 330-447-2540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number446976
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: