Healthcare Provider Details

I. General information

NPI: 1528241908
Provider Name (Legal Business Name): TRACY J SORRELL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2007
Last Update Date: 12/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11210 95TH ST
COAL VALLEY IL
61240-9360
US

IV. Provider business mailing address

1667 320TH ST
SHERRARD IL
61281-8503
US

V. Phone/Fax

Practice location:
  • Phone: 309-799-3161
  • Fax:
Mailing address:
  • Phone: 309-593-2648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: