Provider Demographics
NPI:1770177263
Name:TRACIE L. SIPPLE, PT
Entity type:Organization
Organization Name:TRACIE L. SIPPLE, PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:LORIECE
Authorized Official - Last Name:SIPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:505-220-3401
Mailing Address - Street 1:PO BOX 504
Mailing Address - Street 2:
Mailing Address - City:LAFOX
Mailing Address - State:IL
Mailing Address - Zip Code:60147-0504
Mailing Address - Country:US
Mailing Address - Phone:505-220-3401
Mailing Address - Fax:
Practice Address - Street 1:312 E READER ST
Practice Address - Street 2:
Practice Address - City:ELBURN
Practice Address - State:IL
Practice Address - Zip Code:60119-6014
Practice Address - Country:US
Practice Address - Phone:505-220-3401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty