Healthcare Provider Details

I. General information

NPI: 1407851199
Provider Name (Legal Business Name): TRACY RENE MCAREAVEY RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 S 1ST ST
BLACKWELL OK
74631-3825
US

IV. Provider business mailing address

706 S 1ST ST
BLACKWELL OK
74631-3825
US

V. Phone/Fax

Practice location:
  • Phone: 580-363-1111
  • Fax: 580-363-1116
Mailing address:
  • Phone: 580-363-1111
  • Fax: 580-363-1116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2011
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: