Provider Demographics
NPI:1972867711
Name:RICHARDSON, TRACY (DPT,CCCE,CCI)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:DPT,CCCE,CCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 ABERDEEN CT
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3175
Mailing Address - Country:US
Mailing Address - Phone:815-758-0000
Mailing Address - Fax:815-748-3014
Practice Address - Street 1:900 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-1764
Practice Address - Country:US
Practice Address - Phone:815-758-0000
Practice Address - Fax:815-748-3014
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016939174400000X
IL070-0169392251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No174400000XOther Service ProvidersSpecialist