MEDICARE: TRACY COOPER OTR/L

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	225X00000X	Occupational Therapist	056009071	IL

General Provider Information

NPI Number	:	1700201514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY COOPER OTR/L

Provider Business Mailing Address
First Line	:	2506 N CLARK ST
Second Line	:	158
City	:	CHICAGO
State	:	IL
Zip	:	60614-1848
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2506 N CLARK ST # 158
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1848
Country	:	US
Telephone Number	:	312-401-0975
Fax Number	:

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

Provider Enumeration Date	:	03/03/2014
Last Update Date	:	03/03/2014

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Directions to “ TRACY COOPER OTR/L” Practice Location

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