Provider Demographics
NPI:1932659091
Name:POTTER, TRACY MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:POTTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:MARIE
Other - Last Name:CARLYON-POTTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:640 E SAINT CHARLES RD
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-3083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 E SAINT CHARLES RD
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-3083
Practice Address - Country:US
Practice Address - Phone:630-460-4698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.003873225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist