Provider Demographics
NPI:1588938179
Name:MAYFIELD, TRACEY MARIE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:MARIE
Last Name:MAYFIELD
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 BLACKHAWK DR
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2356
Mailing Address - Country:US
Mailing Address - Phone:708-543-7533
Mailing Address - Fax:
Practice Address - Street 1:121 BLACKHAWK DR
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2356
Practice Address - Country:US
Practice Address - Phone:708-543-7533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056005237225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist