Healthcare Provider Details

I. General information

NPI: 1427173913
Provider Name (Legal Business Name): TRACY LYNN BRADY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY SMITH

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 11/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 WATER ST. SALEM CARE AND REHABILITATION
SALEM WV
26426
US

IV. Provider business mailing address

1533 HOFFMAN AVE
CLARKSBURG WV
26301
US

V. Phone/Fax

Practice location:
  • Phone: 304-782-3000
  • Fax:
Mailing address:
  • Phone: 215-675-5027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTEE007620
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number001364
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA4675
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: