Provider Demographics
NPI:1093292773
Name:WONDERO, TRACY LIN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:LIN
Last Name:WONDERO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LIN
Other - Last Name:WELCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7263 GREEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:G1069 N BALLENGER HWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-4431
Practice Address - Country:US
Practice Address - Phone:810-235-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004210225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist