Provider Demographics
NPI:1710292735
Name:HARTLEY, TRACI S (LMT)
Entity Type:Individual
Prefix:MS
First Name:TRACI
Middle Name:S
Last Name:HARTLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5011 N CALIFORNIA AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3617
Mailing Address - Country:US
Mailing Address - Phone:773-562-3500
Mailing Address - Fax:
Practice Address - Street 1:5011 N CALIFORNIA AVE
Practice Address - Street 2:APT 2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3617
Practice Address - Country:US
Practice Address - Phone:773-562-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.010354225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist