Provider Demographics
NPI:1922312271
Name:TYLER, TRACEY M (OTR)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:M
Last Name:TYLER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 CAVIL WAY
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-3772
Mailing Address - Country:US
Mailing Address - Phone:920-360-4052
Mailing Address - Fax:
Practice Address - Street 1:218 CAVIL WAY
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-3772
Practice Address - Country:US
Practice Address - Phone:920-360-4052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2976-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist