Individual
MRS. TRACY RAE JOHANNECK-UTPHALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
3248 SHORTRIDGE DR, RACINE, WI 53402-1367
(414) 550-6670
Mailing address
3248 SHORTRIDGE DR, RACINE, WI 53402-1367
(414) 550-6670
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
1193-27
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1193-27
WISCONSIN LICIENSURE
WI
Enumeration date
11/12/2009
Last updated
11/12/2009
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