Basic Information
| Provider Information | |||||||||
| NPI: | 1265888135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANDT | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | LYNN | ||||||||
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| OtherLastName: | SIMS | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | COTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5778 CHAPIN ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541219443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155284833 | ||||||||
| FaxNumber: | 7155284988 | ||||||||
| Practice Location | |||||||||
| Address1: | 5778 CHAPIN ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541219443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155284833 | ||||||||
| FaxNumber: | 7155284988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2016 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 922-27 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.