Provider Demographics
NPI:1760144000
Name:WITTY, TRACY (OT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:WITTY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69472 SERENITY RD
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-7921
Mailing Address - Country:US
Mailing Address - Phone:760-409-6383
Mailing Address - Fax:855-586-3292
Practice Address - Street 1:69472 SERENITY RD
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-7921
Practice Address - Country:US
Practice Address - Phone:760-409-6383
Practice Address - Fax:855-586-3292
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17910225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist