MEDICARE: TRACY DAWN WHITELEATHER PT

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	225100000X	Physical Therapist	05006313A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649289299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY DAWN WHITELEATHER PT

Provider Business Mailing Address
First Line	:	PO BOX 350034
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43635-0034
Country	:	US
Telephone Number	:	260-420-4400
Fax Number	:	260-420-4448

Provider Business Practice Location Address
First Line	:	3217 LAKE AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5427
Country	:	US
Telephone Number	:	260-420-4400
Fax Number	:	260-420-4448

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

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	09/21/2011

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