Provider Demographics
NPI:1730985029
Name:RIVER, TRACY MICHELLE (MT, CLT)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:MICHELLE
Last Name:RIVER
Suffix:
Gender:F
Credentials:MT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 CYPRESS CV
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-7910
Mailing Address - Country:US
Mailing Address - Phone:407-451-7675
Mailing Address - Fax:
Practice Address - Street 1:262 RED CEDAR ST STE 4
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-8968
Practice Address - Country:US
Practice Address - Phone:843-227-3508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7165225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist