Provider Demographics
NPI:1912140476
Name:BENSON, TRACY MARIE (MOT, OTR/L, CHT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:MARIE
Last Name:BENSON
Suffix:
Gender:F
Credentials:MOT, OTR/L, CHT
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:MARIE
Other - Last Name:EASTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:7224 118TH AVE
Practice Address - Street 2:STE E
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8424
Practice Address - Country:US
Practice Address - Phone:262-857-4400
Practice Address - Fax:262-857-4411
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.007462225X00000X
WIWI5346-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216859295Medicare PIN
P01316887Medicare PIN