Provider Demographics
NPI:1265830806
Name:GIBB, TRACI (ATC, LAT)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:GIBB
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W197N16960 STONEWALL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WI
Mailing Address - Zip Code:53037-8617
Mailing Address - Country:US
Mailing Address - Phone:414-750-9393
Mailing Address - Fax:
Practice Address - Street 1:W197N16960 STONEWALL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WI
Practice Address - Zip Code:53037-8617
Practice Address - Country:US
Practice Address - Phone:414-750-9393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1475-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer