Provider Demographics
NPI:1992143697
Name:GUIDRY, TRACE STEPHEN (PTA)
Entity type:Individual
Prefix:
First Name:TRACE
Middle Name:STEPHEN
Last Name:GUIDRY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5957 9TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642
Mailing Address - Country:US
Mailing Address - Phone:409-982-8878
Mailing Address - Fax:409-982-5519
Practice Address - Street 1:5957 9TH AVE
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-6204
Practice Address - Country:US
Practice Address - Phone:409-982-8878
Practice Address - Fax:409-982-5519
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4051061225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant