Provider Demographics
NPI:1265888135
Name:BRANDT, TRACY LYNN
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:BRANDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNN
Other - Last Name:SIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:5778 CHAPIN ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:WI
Mailing Address - Zip Code:54121-9443
Mailing Address - Country:US
Mailing Address - Phone:715-528-4833
Mailing Address - Fax:715-528-4988
Practice Address - Street 1:5778 CHAPIN ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:WI
Practice Address - Zip Code:54121-9443
Practice Address - Country:US
Practice Address - Phone:715-528-4833
Practice Address - Fax:715-528-4988
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI922-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant