Provider Demographics
NPI:1043551013
Name:PRIDGEON, TRACIE LYNN (PT)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:LYNN
Last Name:PRIDGEON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 NEWPORT DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-1758
Mailing Address - Country:US
Mailing Address - Phone:410-838-2200
Mailing Address - Fax:410-838-3300
Practice Address - Street 1:12 NEWPORT DR
Practice Address - Street 2:SUITE C
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-1758
Practice Address - Country:US
Practice Address - Phone:410-838-2200
Practice Address - Fax:410-838-3300
Is Sole Proprietor?:No
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist