Provider Demographics
NPI:1336976562
Name:TRACEY, DEVON (OTD)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:TRACEY
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10019 FOREST GREEN BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5119
Mailing Address - Country:US
Mailing Address - Phone:502-893-1380
Mailing Address - Fax:
Practice Address - Street 1:10019 FOREST GREEN BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-5119
Practice Address - Country:US
Practice Address - Phone:502-893-1380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY293746225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist