MEDICARE: TRACY LYNN VAN DE YACHT PTA

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	225200000X	Physical Therapy Assistant	901-019	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710076716
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY LYNN VAN DE YACHT PTA

Provider Business Mailing Address
First Line	:	1513 BELLE HOLLOW LN
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54313-3210
Country	:	US
Telephone Number	:	920-434-0104
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 CURRY LN
Second Line	:	N.E.W. CURATIVE REHABILITATION, INC.
City	:	GREEN BAY
State	:	WI
Zip	:	54311-5857
Country	:	US
Telephone Number	:	920-468-9129
Fax Number	:	920-965-2653

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2007

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