Provider Demographics
NPI:1730371444
Name:MASSEY, TRACY LEE (OTR)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:MASSEY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 FLORIDA AVE S
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2152
Mailing Address - Country:US
Mailing Address - Phone:321-634-3688
Mailing Address - Fax:321-504-0955
Practice Address - Street 1:1024 FLORIDA AVE S
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2152
Practice Address - Country:US
Practice Address - Phone:321-634-3688
Practice Address - Fax:321-504-0955
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 10499225X00000X
FLOT10499222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL892345100Medicaid