Healthcare Provider Details

I. General information

NPI: 1316042971
Provider Name (Legal Business Name): TRACY C BALANGUE OTD, OTR/L, CHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6462 W 86TH PL
LOS ANGELES CA
90045-3745
US

IV. Provider business mailing address

6462 W 86TH PL
LOS ANGELES CA
90045-3745
US

V. Phone/Fax

Practice location:
  • Phone: 310-666-2681
  • Fax:
Mailing address:
  • Phone: 310-216-7165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT 6188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: