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General NPI Number Information
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NPI Number | 1386700748
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Entity Type | Individual
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Provider Name | TRACY GRAHAM O.T.
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Gender | Male
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Dates
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Enumeration Date | 12/29/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 90 CLARK AVE # A
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City | TUPELO
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State | MS
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Zip | 38804-2801
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Country | US
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Telephone | 662-840-0535
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Fax | 662-842-7915
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Provider Business Mailing Address
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Address Line | 15 STARLING CRK
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City | BOONEVILLE
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State | MS
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Zip | 38829-3638
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Country | US
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Telephone | 662-416-3283
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT1457
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License Number State | MS
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