Provider Demographics
NPI:1366092983
Name:THOMPSON, TRACIE RENEE (COTA/L)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:RENEE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 TREALOUT DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1481
Mailing Address - Country:US
Mailing Address - Phone:810-593-3119
Mailing Address - Fax:
Practice Address - Street 1:12191 JENNINGS RD
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-9476
Practice Address - Country:US
Practice Address - Phone:810-397-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant