Provider Demographics
NPI:1316254477
Name:GREEN, TRACI DUNCAN (MPT)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:DUNCAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:LYN
Other - Last Name:DUNCAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:6021 STERLING RIVER WAY
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578
Mailing Address - Country:US
Mailing Address - Phone:850-378-2600
Mailing Address - Fax:833-869-6437
Practice Address - Street 1:424 COLLEGE BLVD.
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:FL
Practice Address - Zip Code:32580
Practice Address - Country:US
Practice Address - Phone:850-378-2600
Practice Address - Fax:833-869-6437
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT16099225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist