Provider Demographics
NPI:1659877512
Name:RALICKI, TRACY (OTR)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:RALICKI
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-1037
Mailing Address - Country:US
Mailing Address - Phone:269-637-8411
Mailing Address - Fax:
Practice Address - Street 1:120 BASELINE RD
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-1037
Practice Address - Country:US
Practice Address - Phone:269-637-8411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-31
Last Update Date:2018-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201000385225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology