Provider Demographics
NPI:1851594824
Name:SHAUGHNESSY, TRACEY JOANNE (COTA)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:JOANNE
Last Name:SHAUGHNESSY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MISS
Other - First Name:TRACEY
Other - Middle Name:JOANNE
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:412 MELODY LANE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593
Mailing Address - Country:US
Mailing Address - Phone:608-845-5014
Mailing Address - Fax:
Practice Address - Street 1:407 N 8TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572
Practice Address - Country:US
Practice Address - Phone:608-437-9626
Practice Address - Fax:608-437-9604
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI443027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40646000Medicaid