Provider Demographics
NPI:1952458275
Name:WIEBKING, TRACY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:WIEBKING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:DOHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 BECKS WOODS DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-3835
Practice Address - Country:US
Practice Address - Phone:302-392-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18976225100000X
DEJ10000408225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD76956616OtherBC MARYLAND
0706628000OtherAMERIHEALTH
11247945OtherCAQH
MD5070-0102OtherGHMSI
DE1952458275Medicaid
MD76956616OtherBC MARYLAND
MD233110ZBL8Medicare PIN
P00479919Medicare PIN