Provider Demographics
NPI:1437400454
Name:BREITENSTEIN, TRACY CALLAHAN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:CALLAHAN
Last Name:BREITENSTEIN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:MARGARET
Other - Last Name:CALLAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:1209 W ARTHUR AVE
Mailing Address - Street 2:APT 818
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-6253
Mailing Address - Country:US
Mailing Address - Phone:828-773-3137
Mailing Address - Fax:
Practice Address - Street 1:7000 N MCCORMICK BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-2726
Practice Address - Country:US
Practice Address - Phone:828-773-3137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1510225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist