Healthcare Provider Details

I. General information

NPI: 1841415122
Provider Name (Legal Business Name): TRACY WUTZKE PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 11/29/2021
Certification Date: 11/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9888 CARROLL CENTRE RD STE 216
SAN DIEGO CA
92126-4515
US

IV. Provider business mailing address

9888 CARROLL CENTRE RD STE 216
SAN DIEGO CA
92126-4515
US

V. Phone/Fax

Practice location:
  • Phone: 858-413-7557
  • Fax:
Mailing address:
  • Phone: 858-413-7557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY17239
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY17239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: