Provider Demographics
NPI:1710014824
Name:MCCORMICK, TRACY GENE (ATC)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:GENE
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 N APPLETON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-2737
Mailing Address - Country:US
Mailing Address - Phone:920-882-6595
Mailing Address - Fax:
Practice Address - Street 1:820 E GRANT ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3483
Practice Address - Country:US
Practice Address - Phone:920-831-5050
Practice Address - Fax:920-738-6400
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI290-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI290-039OtherSTATE LICENSE NUMBER