Provider Demographics
NPI:1124356688
Name:UDITSKY, TRACEY GAIL
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:GAIL
Last Name:UDITSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-4432
Mailing Address - Country:US
Mailing Address - Phone:909-973-4365
Mailing Address - Fax:909-510-8196
Practice Address - Street 1:1951 6TH ST
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-4432
Practice Address - Country:US
Practice Address - Phone:909-973-4365
Practice Address - Fax:909-510-8196
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT4910225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist