Provider Demographics
NPI:1841415122
Name:WUTZKE, TRACY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:WUTZKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
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:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17239103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical