Provider Demographics
NPI:1245669050
Name:BOESCH, TRACY LYNN (PTA)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LYNN
Last Name:BOESCH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SEBEWAING
Mailing Address - State:MI
Mailing Address - Zip Code:48759-9756
Mailing Address - Country:US
Mailing Address - Phone:810-853-8992
Mailing Address - Fax:989-872-2204
Practice Address - Street 1:4782 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CASS CITY
Practice Address - State:MI
Practice Address - Zip Code:48726-1049
Practice Address - Country:US
Practice Address - Phone:989-872-2174
Practice Address - Fax:989-872-2204
Is Sole Proprietor?:No
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001175225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5502001175Medicaid