Provider Demographics
NPI:1386700748
Name:GRAHAM, TRACY (OT)
Entity type:Individual
Prefix:MR
First Name:TRACY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 STARLING CRK
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-3638
Mailing Address - Country:US
Mailing Address - Phone:662-416-3283
Mailing Address - Fax:
Practice Address - Street 1:90 CLARK AVE # A
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-2801
Practice Address - Country:US
Practice Address - Phone:662-840-0535
Practice Address - Fax:662-842-7915
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1457225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist