Provider Demographics
NPI:1871664185
Name:BROOK, TRACEY (PT)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:BROOK
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 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:1003 MILL POND DR
Practice Address - Street 2:SUITE C
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2608
Practice Address - Country:US
Practice Address - Phone:765-653-8494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05002823A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000175273OtherBCBS
IN200193160Medicaid
IN200193160Medicaid