Provider Demographics
NPI:1245317007
Name:DEVALL, TRACY (PT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DEVALL
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 1:399 MCCARTHY LOOP
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-9146
Mailing Address - Country:US
Mailing Address - Phone:406-777-3523
Mailing Address - Fax:406-777-3523
Practice Address - Street 1:3802 EASTSIDE HWY
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MT
Practice Address - Zip Code:59870-2224
Practice Address - Country:US
Practice Address - Phone:406-777-3523
Practice Address - Fax:406-777-3523
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1552PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0345712Medicaid