Healthcare Provider Details

I. General information

NPI: 1396076527
Provider Name (Legal Business Name): TRACY REHABILITATIVE SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2010
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 RIVIERA DR
TUTTLE OK
73089-8109
US

IV. Provider business mailing address

1802 RIVIERA DR
TUTTLE OK
73089-8109
US

V. Phone/Fax

Practice location:
  • Phone: 405-626-8701
  • Fax:
Mailing address:
  • Phone: 405-626-8701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4228
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3518
License Number StateOK

VIII. Authorized Official

Name: MRS. MEGAN DEE TRACY
Title or Position: OWNER/PRESIDENT
Credential: M.S.CCC-SLP
Phone: 405-626-8701