Provider Demographics
NPI:1750827499
Name:TRACY WUTZKE, PSY.D
Entity Type:Organization
Organization Name:TRACY WUTZKE, PSY.D
Other - Org Name:WUTZKE, TRACY
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WUTZKE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:858-413-7557
Mailing Address - Street 1:9888 CARROLL CENTRE RD STE 216
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4515
Mailing Address - Country:US
Mailing Address - Phone:858-413-7557
Mailing Address - Fax:858-217-5285
Practice Address - Street 1:9888 CARROLL CENTRE RD STE 216
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4515
Practice Address - Country:US
Practice Address - Phone:858-413-7557
Practice Address - Fax:858-217-5285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17239103TC0700X
CA52458106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100058167001OtherBLUE SHIELD OF CALIFORNIA
CA240986OtherMHN
CA134599523187OtherHUMANA
CA0009236145OtherAETNA