Provider Demographics
NPI:1477513620
Name:STEPHEN, TRACY (ATC/LAT)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:
Last Name:STEPHEN
Suffix:
Gender:F
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 W GARTNER RD
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-7148
Mailing Address - Country:US
Mailing Address - Phone:630-369-9582
Mailing Address - Fax:
Practice Address - Street 1:633 W GARTNER RD
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-7148
Practice Address - Country:US
Practice Address - Phone:630-369-9582
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist