Provider Demographics
NPI:1427333764
Name:WHITE, TRACEY VANESSA (OTR/L)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:VANESSA
Last Name:WHITE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6631 SW 18TH ST
Mailing Address - Street 2:APT. 103
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33023-2169
Mailing Address - Country:US
Mailing Address - Phone:954-662-2067
Mailing Address - Fax:954-989-3052
Practice Address - Street 1:6631 SW 18TH ST
Practice Address - Street 2:APT. 103
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33023-2169
Practice Address - Country:US
Practice Address - Phone:954-662-2067
Practice Address - Fax:954-989-3052
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 14690225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006493200Medicaid