Provider Demographics
NPI:1194912428
Name:SMITH, TRACI MARIE (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4719 FAIRFAX LOOP
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-5827
Mailing Address - Country:US
Mailing Address - Phone:701-391-2384
Mailing Address - Fax:
Practice Address - Street 1:3100 W LAKEWAY RD STE 1
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6373
Practice Address - Country:US
Practice Address - Phone:307-622-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1480225X00000X
ND935225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist