Provider Demographics
NPI:1891069167
Name:VINCENT, TRACY JO (DPT)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:JO
Last Name:VINCENT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 W 75TH ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:MERRIAM
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2209
Mailing Address - Country:US
Mailing Address - Phone:913-894-1910
Mailing Address - Fax:877-913-1174
Practice Address - Street 1:10000 W 75TH ST
Practice Address - Street 2:SUITE 250
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-2209
Practice Address - Country:US
Practice Address - Phone:913-894-1910
Practice Address - Fax:877-913-1174
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP13567225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212990Medicaid