Basic Information
| Provider Information | |||||||||
| NPI: | 1104110410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRACEY | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | ELLA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOLINE | ||||||||
| OtherFirstName: | CARRIE | ||||||||
| OtherMiddleName: | ELLA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 625 ENTERPRISE DR | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605238813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305751932 | ||||||||
| FaxNumber: | 6309285032 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 13TH ST | ||||||||
| Address2: | STE B | ||||||||
| City: | BELLE PLAINE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522081521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3194346150 | ||||||||
| FaxNumber: | 3194346188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2011 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 004679 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.