Provider Demographics
NPI:1821183658
Name:GOTZ, TRACI M (PT)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:M
Last Name:GOTZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7706 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5606
Mailing Address - Country:US
Mailing Address - Phone:262-496-4908
Mailing Address - Fax:262-653-1248
Practice Address - Street 1:7706 26TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5606
Practice Address - Country:US
Practice Address - Phone:262-496-4908
Practice Address - Fax:262-653-1248
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist