Provider Demographics
NPI:1548969082
Name:SOULE, TRACI ANN (CTRS)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:ANN
Last Name:SOULE
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:TRACI
Other - Middle Name:ANN
Other - Last Name:TIBBETTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1032 RAINBOW AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3483
Mailing Address - Country:US
Mailing Address - Phone:314-369-2609
Mailing Address - Fax:
Practice Address - Street 1:1032 RAINBOW AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3483
Practice Address - Country:US
Practice Address - Phone:314-369-2609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225800000X
NY85396225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist