Provider Demographics
NPI:1598830457
Name:VILLIGER, TRACEY LEA (PT)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:LEA
Last Name:VILLIGER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 KEOLU DR
Mailing Address - Street 2:C 7-A
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-3845
Mailing Address - Country:US
Mailing Address - Phone:808-261-9792
Mailing Address - Fax:808-262-8600
Practice Address - Street 1:1020 KEOLU DR
Practice Address - Street 2:C 7-A
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-3845
Practice Address - Country:US
Practice Address - Phone:808-261-9792
Practice Address - Fax:808-262-8600
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI55424701Medicaid
HI55424701Medicaid