Basic Information
| Provider Information | |||||||||
| NPI: | 1447339007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROYAL | ||||||||
| FirstName: | TRACI | ||||||||
| MiddleName: | PETERS | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8719 SAGEBRUSH LN | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782175836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2108269929 | ||||||||
| FaxNumber: | 2103406437 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 NE LOOP 410 | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782165829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103402627 | ||||||||
| FaxNumber: | 2103406437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 109144 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8T1334 | 01 | TX | BLUE CROSS BLUE SHEILD | OTHER |