Basic Information
| Provider Information | |||||||||
| NPI: | 1407101306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REED | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LEAVELLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LEAVELLE | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | D | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 199 N BROOKMOORE DRIVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397052024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623276705 | ||||||||
| FaxNumber: | 6623276760 | ||||||||
| Practice Location | |||||||||
| Address1: | 1781B COMMONS NORTH LOOP | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354063577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057520845 | ||||||||
| FaxNumber: | 2057520866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH6469 | AL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1003819608 | 01 | AL | GROUP NPI | OTHER | 529917620 | 05 | AL | MEDICAID |