Provider Demographics
NPI:1508098526
Name:WICKERT, TRACI LYNN (LPTA,CWS)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:LYNN
Last Name:WICKERT
Suffix:
Gender:F
Credentials:LPTA,CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8078 BURWELL RD
Mailing Address - Street 2:
Mailing Address - City:CATLETT
Mailing Address - State:VA
Mailing Address - Zip Code:20119-1801
Mailing Address - Country:US
Mailing Address - Phone:540-219-1785
Mailing Address - Fax:
Practice Address - Street 1:8078 BURWELL RD
Practice Address - Street 2:
Practice Address - City:CATLETT
Practice Address - State:VA
Practice Address - Zip Code:20119-1801
Practice Address - Country:US
Practice Address - Phone:540-219-1785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306000446225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant