Provider Demographics
NPI:1598271496
Name:PROUD, RACHEL LYNN (MT)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:LYNN
Last Name:PROUD
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 INNSBRUCK LN
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-1128
Mailing Address - Country:US
Mailing Address - Phone:708-557-6816
Mailing Address - Fax:
Practice Address - Street 1:3235 VOLLMER RD STE 138
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2040
Practice Address - Country:US
Practice Address - Phone:708-557-6816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-14
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.002539225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist