Provider Demographics
NPI:1447027529
Name:JUSTICE, TRAE BERKELEY
Entity type:Individual
Prefix:
First Name:TRAE
Middle Name:BERKELEY
Last Name:JUSTICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6435 AUTUMN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6933
Mailing Address - Country:US
Mailing Address - Phone:662-910-0353
Mailing Address - Fax:
Practice Address - Street 1:795 RIDGE LAKE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-9475
Practice Address - Country:US
Practice Address - Phone:901-255-6532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7666225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant