Provider Demographics
NPI:1336498211
Name:ROBERTS-HISLOP, TRACY SUZANNE (DPT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:SUZANNE
Last Name:ROBERTS-HISLOP
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6131
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:886 MAGNOLIA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3105
Practice Address - Country:US
Practice Address - Phone:951-340-3402
Practice Address - Fax:951-340-3416
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 39348225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGP197ZMedicare PIN
CACA173637Medicare PIN