Provider Demographics
NPI:1306373675
Name:SHEPARD, TRACEE MICHELLE (PTA)
Entity type:Individual
Prefix:
First Name:TRACEE
Middle Name:MICHELLE
Last Name:SHEPARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 MELISSAS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-8813
Mailing Address - Country:US
Mailing Address - Phone:573-587-2342
Mailing Address - Fax:
Practice Address - Street 1:3120 INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5043
Practice Address - Country:US
Practice Address - Phone:573-651-8242
Practice Address - Fax:573-651-8246
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO117109208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation