Provider Demographics
NPI:1962560177
Name:TITCHNER, TRACY (PT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:TITCHNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 BLAIR PARK RD
Mailing Address - Street 2:PO BOX 1064
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7435
Mailing Address - Country:US
Mailing Address - Phone:802-879-0909
Mailing Address - Fax:802-879-3095
Practice Address - Street 1:151 BLAIR PARK RD
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7435
Practice Address - Country:US
Practice Address - Phone:802-879-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0002801225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT43V034OtherMVP
VT00019760OtherBCBS
VT272923OtherCIGNA
VT1007612Medicaid
VT272923OtherCIGNA