Provider Demographics
NPI:1306148481
Name:ANDERSEN, TRACI LEIGH (DPT)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:LEIGH
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 BRICKELL AVE
Mailing Address - Street 2:APARTMENT A506
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33129-1621
Mailing Address - Country:US
Mailing Address - Phone:757-869-1938
Mailing Address - Fax:
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:REHABILITATION HOSPITAL ROOM 146
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-585-6334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 25730225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist