Provider Demographics
NPI:1497715254
Name:TINOCO, TRUDY SHEEDY (OT)
Entity Type:Individual
Prefix:
First Name:TRUDY
Middle Name:SHEEDY
Last Name:TINOCO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1642
Mailing Address - Country:US
Mailing Address - Phone:608-375-6311
Mailing Address - Fax:608-375-6315
Practice Address - Street 1:205 PARKER ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1642
Practice Address - Country:US
Practice Address - Phone:608-375-6311
Practice Address - Fax:608-375-6315
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-001970225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK23195Medicare ID - Type UnspecifiedGROUP 433440