Provider Demographics
NPI:1376766477
Name:WAGNER, TRACEY (RPT)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 OAK PARK
Mailing Address - Street 2:209
Mailing Address - City:OAK PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91377
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 DESOTO AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLSQ
Practice Address - State:CA
Practice Address - Zip Code:91365
Practice Address - Country:US
Practice Address - Phone:818-719-2930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 261582251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic