Provider Demographics
NPI:1770961609
Name:MCCRACKEN, KAYCIE MAY (PT, DPT, LAT)
Entity type:Individual
Prefix:
First Name:KAYCIE
Middle Name:MAY
Last Name:MCCRACKEN
Suffix:
Gender:F
Credentials:PT, DPT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:WI
Mailing Address - Zip Code:54624-8627
Mailing Address - Country:US
Mailing Address - Phone:608-778-9616
Mailing Address - Fax:
Practice Address - Street 1:331 S WATER ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1726
Practice Address - Country:US
Practice Address - Phone:608-269-3168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2019-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
WI14683-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer