MEDICARE: MALISSA TRACY, LMT

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	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1336493956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALISSA TRACY, LMT

Provider Business Mailing Address
First Line	:	8648 TROY PIKE
Second Line	:	SUITE D
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-1057
Country	:	US
Telephone Number	:	937-233-1755
Fax Number	:	937-233-1655

Provider Business Practice Location Address
First Line	:	8648 TROY PIKE
Second Line	:	SUITE D
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-1057
Country	:	US
Telephone Number	:	937-233-1755
Fax Number	:	937-233-1655

Authorized Official
Title or Position	:	OWNER/PRACTITIONER
Name	:	MS. MALISSA L TRACY
Credential	:	LMT
Telephone Number	:	937-233-1755

Provider Enumeration Date	:	11/05/2012
Last Update Date	:	11/05/2012

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