Provider Demographics
NPI:1265631220
Name:LAUDER, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:LAUDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 S 300 E
Mailing Address - Street 2:
Mailing Address - City:KOUTS
Mailing Address - State:IN
Mailing Address - Zip Code:46347
Mailing Address - Country:US
Mailing Address - Phone:219-462-8149
Mailing Address - Fax:
Practice Address - Street 1:6040 LUTE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-5008
Practice Address - Country:US
Practice Address - Phone:219-763-6858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002130A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant