Basic Information
| Provider Information | |||||||||
| NPI: | 1659877512 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RALICKI | ||||||||
| FirstName: | TRACY | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490901037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696378411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490901037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696378411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2018 | ||||||||
| LastUpdateDate: | 03/31/2018 | ||||||||
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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 | 225XG0600X | 5201000385 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Gerontology |
No ID Information.