Provider Demographics
NPI:1104110410
Name:GRACEY, CARRIE ELLA (PT)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:ELLA
Last Name:GRACEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ELLA
Other - Last Name:WOLINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1932
Mailing Address - Fax:630-928-5032
Practice Address - Street 1:509 13TH ST
Practice Address - Street 2:STE B
Practice Address - City:BELLE PLAINE
Practice Address - State:IA
Practice Address - Zip Code:52208-1521
Practice Address - Country:US
Practice Address - Phone:319-434-6150
Practice Address - Fax:319-434-6188
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004679225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist