Provider Demographics
NPI:1972713725
Name:SIMMONS, TRACI ELLEN (PT)
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:ELLEN
Last Name:SIMMONS
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 1:4631 OAKLAWN DR
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-5206
Mailing Address - Country:US
Mailing Address - Phone:417-627-0120
Mailing Address - Fax:
Practice Address - Street 1:2727 MC CLELLAND BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1626
Practice Address - Country:US
Practice Address - Phone:417-781-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO02137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist