Provider Demographics
NPI:1205836707
Name:SIPPLE, TRACIE LORIECE (PT)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:LORIECE
Last Name:SIPPLE
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:PO BOX 504
Mailing Address - Street 2:
Mailing Address - City:LAFOX
Mailing Address - State:IL
Mailing Address - Zip Code:60147
Mailing Address - Country:US
Mailing Address - Phone:505-220-3401
Mailing Address - Fax:
Practice Address - Street 1:312 E READER ST
Practice Address - Street 2:
Practice Address - City:ELBURN
Practice Address - State:IL
Practice Address - Zip Code:60119
Practice Address - Country:US
Practice Address - Phone:505-220-3401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2646225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2646OtherSTATE OF NM REG & LICENS.
NMP00348972OtherRAILROAD MEDICARE
NM000Q0406OtherMEDICAID GROUP #
NMP00348972OtherRAILROAD MEDICARE