Provider Demographics
NPI:1205232063
Name:ANDERSON, TRACY LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:WI
Mailing Address - Zip Code:53502-9533
Mailing Address - Country:US
Mailing Address - Phone:608-214-9354
Mailing Address - Fax:
Practice Address - Street 1:704 E STATE ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:WI
Practice Address - Zip Code:53502-9533
Practice Address - Country:US
Practice Address - Phone:608-214-9354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11357 146171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor