Provider Demographics
NPI:1710076716
Name:VAN DE YACHT, TRACY LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:VAN DE YACHT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 BELLE HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-3210
Mailing Address - Country:US
Mailing Address - Phone:920-434-0104
Mailing Address - Fax:
Practice Address - Street 1:2900 CURRY LN
Practice Address - Street 2:N.E.W. CURATIVE REHABILITATION, INC.
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5857
Practice Address - Country:US
Practice Address - Phone:920-468-9129
Practice Address - Fax:920-965-2653
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI901-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40331900Medicaid