Provider Demographics
NPI:1285248070
Name:TRACY, MARY JANE (LMBT NC #6877)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:TRACY
Suffix:
Gender:F
Credentials:LMBT NC #6877
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 SUMMEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-7930
Mailing Address - Country:US
Mailing Address - Phone:704-301-5470
Mailing Address - Fax:
Practice Address - Street 1:1800 SUMMEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-7930
Practice Address - Country:US
Practice Address - Phone:704-301-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6877225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist