Healthcare Provider Details

I. General information

NPI: 1750827499
Provider Name (Legal Business Name): TRACY WUTZKE, PSY.D
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 11/14/2021
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: 858-217-5285
Mailing address:
  • Phone: 858-413-7557
  • Fax: 858-217-5285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY17239
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number52458
License Number StateCA

VIII. Authorized Official

Name: DR. TRACY WUTZKE
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSY.D
Phone: 858-413-7557