Provider Demographics
NPI:1396134524
Name:CORTEZ, GRACE ELIZABETH (LAT)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ELIZABETH
Last Name:CORTEZ
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 DEVLIN RD APT 202
Mailing Address - Street 2:
Mailing Address - City:INGLESIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60041-9714
Mailing Address - Country:US
Mailing Address - Phone:815-757-5111
Mailing Address - Fax:
Practice Address - Street 1:3801 SPRING ST
Practice Address - Street 2:ORTHOPEDIC DEPARTMENT
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53405-1667
Practice Address - Country:US
Practice Address - Phone:262-687-5838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39-7442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer