Provider Demographics
NPI:1760742589
Name:VIDAS, TRACIE ANNE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:ANNE
Last Name:VIDAS
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 1:4313 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1501
Mailing Address - Country:US
Mailing Address - Phone:262-654-2800
Mailing Address - Fax:262-654-2800
Practice Address - Street 1:4313 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1501
Practice Address - Country:US
Practice Address - Phone:262-654-2800
Practice Address - Fax:262-654-2800
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-26
Last Update Date:2012-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1101-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant