Provider Demographics
NPI:1962208793
Name:WHITESELL, TRACEY JOLYNN (OTR)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:JOLYNN
Last Name:WHITESELL
Suffix:
Gender:
Credentials:OTR
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:JOLYNN
Other - Last Name:HASSLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:5622 W STATE ROAD 340
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-7867
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5622 W STATE ROAD 340
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-7867
Practice Address - Country:US
Practice Address - Phone:812-249-4795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-21
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005065A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist