Provider Demographics
NPI:1568440154
Name:HEADLEY, TRACI KAY (ATC)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:KAY
Last Name:HEADLEY
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 W FAY AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2123
Mailing Address - Country:US
Mailing Address - Phone:630-516-0967
Mailing Address - Fax:
Practice Address - Street 1:12400 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1440
Practice Address - Country:US
Practice Address - Phone:708-671-0771
Practice Address - Fax:708-671-0767
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer