Provider Demographics
NPI:1538567938
Name:DOUTHARD, TRACY LYNN (PT, DMIN)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNN
Last Name:DOUTHARD
Suffix:
Gender:F
Credentials:PT, DMIN
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:MOSHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:460 HIGHPOINTS RDG
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-7814
Mailing Address - Country:US
Mailing Address - Phone:417-230-1662
Mailing Address - Fax:
Practice Address - Street 1:714 STATE HIGHWAY 248 STE 503
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616
Practice Address - Country:US
Practice Address - Phone:417-230-1662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-17
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011028225100000X
MO2015002291225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist