Provider Demographics
NPI:1588809578
Name:DWORSHAKWINTERBOTTOM, TRACI LYNN
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNN
Last Name:DWORSHAKWINTERBOTTOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5724 ADRIENNE CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8257
Mailing Address - Country:US
Mailing Address - Phone:719-271-5200
Mailing Address - Fax:
Practice Address - Street 1:1710 W COLORADO AVE UNIT B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-3886
Practice Address - Country:US
Practice Address - Phone:719-271-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO711417225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist