Basic Information
| Provider Information | |||||||||
| NPI: | 1801100490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOWNSEND | ||||||||
| FirstName: | TRACIE | ||||||||
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| OtherLastName: | BAUMANN | ||||||||
| OtherFirstName: | TRACIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10831 W MORLEY DR | ||||||||
| Address2: | |||||||||
| City: | WILLIS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481919676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346462781 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25800 W 11 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480346196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486150852 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2010 | ||||||||
| LastUpdateDate: | 03/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502000954 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.