Provider Demographics
NPI:1306971544
Name:ELLIOTT, TRACEY KELLY (PT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:KELLY
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 JULIA WAY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4071
Mailing Address - Country:US
Mailing Address - Phone:850-862-7227
Mailing Address - Fax:
Practice Address - Street 1:4 JACKSON ST NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4925
Practice Address - Country:US
Practice Address - Phone:850-862-7227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT226152251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics