Provider Demographics
NPI:1083733000
Name:MARAS, TRACEY LYNN (OTR)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LYNN
Last Name:MARAS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9469
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62791-9469
Mailing Address - Country:US
Mailing Address - Phone:217-652-3286
Mailing Address - Fax:
Practice Address - Street 1:1301 S KOKE MILL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-9252
Practice Address - Country:US
Practice Address - Phone:217-547-9108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.001359225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1181750001Medicare NSC