Individual
MRS. TRACIE RENEE GRAHAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
O.T.
Contact information
Practice address
413 W. TYLER COVE, WEST MEMPHIS, AR 72301
(870) 733-1200
(870) 732-3269
Mailing address
4734 BETHAY DR, MEMPHIS, TN 38125-5700
(901) 494-3710
(870) 733-1200
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
OTR1280
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
5U518
AR BLUECROSS BLUESHIELD
AR
Enumeration date
03/26/2007
Last updated
07/09/2007
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