Provider Demographics
NPI:1285960229
Name:RENNA, TRACY (OTR)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:
Last Name:RENNA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4904 NE 123RD LN
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-9630
Mailing Address - Country:US
Mailing Address - Phone:352-512-6513
Mailing Address - Fax:
Practice Address - Street 1:4904 NE 123RD LN
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:FL
Practice Address - Zip Code:34484
Practice Address - Country:US
Practice Address - Phone:352-512-6513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT14017225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00313539Medicaid
NY01815443Medicaid
NY00313539Medicaid
NY01815443Medicaid