Provider Demographics
NPI:1124710827
Name:BRUNSON, TRACEY ROGERS (PTA)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:ROGERS
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:ROGERS
Other - Last Name:BUCKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:123 WEXHURST RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-8515
Mailing Address - Country:US
Mailing Address - Phone:803-447-3725
Mailing Address - Fax:
Practice Address - Street 1:711 CHESTERFIELD HWY
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-7002
Practice Address - Country:US
Practice Address - Phone:843-537-7881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3077225200000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant