Provider Demographics
NPI:1669847448
Name:DERR, TRACI LYNN (HHP, CMT)
Entity Type:Individual
Prefix:MISS
First Name:TRACI
Middle Name:LYNN
Last Name:DERR
Suffix:
Gender:F
Credentials:HHP, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8528 N MAGNOLIA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-4692
Mailing Address - Country:US
Mailing Address - Phone:619-972-8650
Mailing Address - Fax:
Practice Address - Street 1:8528 N MAGNOLIA AVE STE 102
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-4692
Practice Address - Country:US
Practice Address - Phone:619-972-8650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-05
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61672225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist