Provider Demographics
NPI:1962702464
Name:BLOCKER, TRACEY COSTON (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:COSTON
Last Name:BLOCKER
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 1:1102 SMITH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5739
Mailing Address - Country:US
Mailing Address - Phone:229-227-1433
Mailing Address - Fax:229-226-6353
Practice Address - Street 1:1102 SMITH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5739
Practice Address - Country:US
Practice Address - Phone:229-227-1433
Practice Address - Fax:229-226-6353
Is Sole Proprietor?:No
Enumeration Date:2010-10-30
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105853225X00000X
GAOT005242225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist