Provider Demographics
NPI:1104643154
Name:RUTHERFORD, TRACY (OT)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5798 W BOULDER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-8611
Mailing Address - Country:US
Mailing Address - Phone:317-502-7359
Mailing Address - Fax:
Practice Address - Street 1:5798 W BOULDER CREEK DR
Practice Address - Street 2:
Practice Address - City:NEW PALESTINE
Practice Address - State:IN
Practice Address - Zip Code:46163-8611
Practice Address - Country:US
Practice Address - Phone:317-502-7359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003627A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist