Individual
TRACY LANE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA/L
Contact information
Practice address
1910 E MCCORD ST, CENTRALIA, IL 62801-6586
(618) 533-1200
Mailing address
712 THOMAS ST, IUKA, IL 62849-1137
(618) 335-0688
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
057.003623
IL
Other
Enumeration date
03/14/2021
Last updated
03/14/2021
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