Provider Demographics
NPI:1437663986
Name:WALLACE, TRACY DAWN (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:DAWN
Last Name:WALLACE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 NORMANDY LN
Mailing Address - Street 2:
Mailing Address - City:ATHERTON
Mailing Address - State:CA
Mailing Address - Zip Code:94027-3816
Mailing Address - Country:US
Mailing Address - Phone:650-380-9483
Mailing Address - Fax:
Practice Address - Street 1:1290 LAWRENCE STATION RD
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94089-2220
Practice Address - Country:US
Practice Address - Phone:408-743-5332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8081225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics