Provider Demographics
NPI:1053439778
Name:WEAR, TRACEY (LMT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:WEAR
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9424 N 2ND PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2010
Mailing Address - Country:US
Mailing Address - Phone:602-331-4095
Mailing Address - Fax:
Practice Address - Street 1:8900 N CENTRAL AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2845
Practice Address - Country:US
Practice Address - Phone:602-740-3594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-04765P225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist