Provider Demographics
NPI:1972504769
Name:RICHARDSON, TRACI L (DPT)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:RICHARDSON
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:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:BOALSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16827-0218
Mailing Address - Country:US
Mailing Address - Phone:814-441-9183
Mailing Address - Fax:833-277-6195
Practice Address - Street 1:1146 KAREN ST
Practice Address - Street 2:
Practice Address - City:BOALSBURG
Practice Address - State:PA
Practice Address - Zip Code:16827-1642
Practice Address - Country:US
Practice Address - Phone:814-441-9183
Practice Address - Fax:833-277-6195
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT016580225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011155610005Medicaid
PA101115561/0001Medicaid
PA50037524OtherCAPITAL BLUE CROSS
PA240446OtherHEALTH AMERICA
PA001612726OtherHIGHMARK
PA080351RBVMedicare PIN
PA10111556110001Medicaid