MEDICARE: MRS. TRACEY LIN HARRIS LPT

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	6096	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	079PR	OTHER	NC	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1659392322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACEY LIN HARRIS LPT

Provider Business Mailing Address
First Line	:	402 L PENNY LANE
Second Line	:
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557
Country	:	US
Telephone Number	:	252-240-7466
Fax Number	:

Provider Business Practice Location Address
First Line	:	534 N 35TH ST
Second Line	:	STE D
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-3182
Country	:	US
Telephone Number	:	252-726-1802
Fax Number	:	252-726-1805

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

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	06/21/2011

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