Basic Information
| Provider Information | |||||||||
| NPI: | 1376766477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | TRACEY | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 675 OAK PARK | ||||||||
| Address2: | 209 | ||||||||
| City: | OAK PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91377 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5601 DESOTO AVE | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLSQ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187192930 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PT 26158 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.