Provider Demographics
NPI:1588358451
Name:BRAKE, TRACEY RENEE
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:RENEE
Last Name:BRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10061 SWITCHYARD DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-8115
Mailing Address - Country:US
Mailing Address - Phone:704-777-8919
Mailing Address - Fax:
Practice Address - Street 1:19900 S MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6513
Practice Address - Country:US
Practice Address - Phone:704-777-8919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19730225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist