Provider Demographics
NPI:1679705909
Name:BLOEDORN, TRACI RAE (ARCB)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:RAE
Last Name:BLOEDORN
Suffix:
Gender:F
Credentials:ARCB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N8380 OLD HIGHWAY 47
Mailing Address - Street 2:
Mailing Address - City:BLACK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:54106-9152
Mailing Address - Country:US
Mailing Address - Phone:920-525-3011
Mailing Address - Fax:
Practice Address - Street 1:N8380 OLD HIGHWAY 47
Practice Address - Street 2:
Practice Address - City:BLACK CREEK
Practice Address - State:WI
Practice Address - Zip Code:54106-9152
Practice Address - Country:US
Practice Address - Phone:920-525-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIBO1207173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIBO1207OtherARCB NATIONAL CERTIFICATION NUMBER BO1207