Provider Demographics
NPI:1184206930
Name:LAUTENSLAGER, TRACY ROUTH (LPT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ROUTH
Last Name:LAUTENSLAGER
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 SUNRISE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4106
Mailing Address - Country:US
Mailing Address - Phone:530-321-3399
Mailing Address - Fax:
Practice Address - Street 1:406 SUNRISE AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4106
Practice Address - Country:US
Practice Address - Phone:530-321-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30908167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician