Healthcare Provider Details

I. General information

NPI: 1962453035
Provider Name (Legal Business Name): TRACEY SUE YOST OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14101 ROCK CANYON DR
CENTREVILLE VA
20121
US

IV. Provider business mailing address

14101 ROCK CANYON DR
CENTREVILLE VA
20121-3860
US

V. Phone/Fax

Practice location:
  • Phone: 937-716-4389
  • Fax:
Mailing address:
  • Phone: 937-716-4389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119004309
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: