MEDICARE: MRS. TRACI KAY HEADLEY ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer		IL

General Provider Information

NPI Number	:	1568440154
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACI KAY HEADLEY ATC

Provider Business Mailing Address
First Line	:	635 W FAY AVE
Second Line	:
City	:	ELMHURST
State	:	IL
Zip	:	60126-2123
Country	:	US
Telephone Number	:	630-516-0967
Fax Number	:

Provider Business Practice Location Address
First Line	:	12400 S HARLEM AVE
Second Line	:
City	:	PALOS HEIGHTS
State	:	IL
Zip	:	60463-1440
Country	:	US
Telephone Number	:	708-671-0771
Fax Number	:	708-671-0767

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2006
Last Update Date	:	07/08/2007

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