Provider Demographics
NPI:1508064197
Name:STROM, TRACY CATHERINE (COTA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:CATHERINE
Last Name:STROM
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 VENUS AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-0919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 E BROWN ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:WI
Practice Address - Zip Code:54722-9346
Practice Address - Country:US
Practice Address - Phone:715-286-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1685-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40899100Medicaid