MEDICARE: TRACI LYNN WHITE LPTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	TE1000546	PA

General Provider Information

NPI Number	:	1194929737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACI LYNN WHITE LPTA

Provider Business Mailing Address
First Line	:	1158 E HORTTER ST
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19150-3105
Country	:	US
Telephone Number	:	215-910-3662
Fax Number	:	215-247-6006

Provider Business Practice Location Address
First Line	:	1158 E HORTTER ST
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19150-3105
Country	:	US
Telephone Number	:	215-910-3662
Fax Number	:	215-247-6006

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2007
Last Update Date	:	08/26/2016

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