Provider Demographics
NPI:1427174226
Name:DAUGHERTY, TRACY ANN (MS, ATC, PTA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:DAUGHERTY
Suffix:
Gender:F
Credentials:MS, ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 CYPRESS AVE
Mailing Address - Street 2:
Mailing Address - City:ELKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62932-2526
Mailing Address - Country:US
Mailing Address - Phone:618-568-2543
Mailing Address - Fax:
Practice Address - Street 1:200 N EMERALD LN STE 1A
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2100
Practice Address - Country:US
Practice Address - Phone:618-549-9449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer