Provider Demographics
NPI:1104809052
Name:FARREY, TRACY LYN (PT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYN
Last Name:FARREY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:PETRI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:1271 N 6TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3360
Practice Address - Country:US
Practice Address - Phone:414-978-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269616Medicaid
OR130911Medicare ID - Type Unspecified