Provider Demographics
NPI:1235714924
Name:LANE, TRACY (COTA/L)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:IL
Mailing Address - Zip Code:62849-1137
Mailing Address - Country:US
Mailing Address - Phone:618-335-0688
Mailing Address - Fax:
Practice Address - Street 1:1910 E MCCORD ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-6586
Practice Address - Country:US
Practice Address - Phone:618-533-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-14
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003623224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant