Provider Demographics
NPI:1447728209
Name:OSBURN, TRACI MARIE (PT)
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:MARIE
Last Name:OSBURN
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 1:7631 BAKER HWY
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-9657
Mailing Address - Country:US
Mailing Address - Phone:517-513-9989
Mailing Address - Fax:517-266-1800
Practice Address - Street 1:730 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1445
Practice Address - Country:US
Practice Address - Phone:517-266-1700
Practice Address - Fax:517-266-1800
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011058225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501011058Medicaid