Healthcare Provider Details

I. General information

NPI: 1659563716
Provider Name (Legal Business Name): TRACY TYCER OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 08/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 LANAKILA AVE RM 210
HONOLULU HI
96817-2115
US

IV. Provider business mailing address

1700 LANAKILA AVE RM 210
HONOLULU HI
96817-2115
US

V. Phone/Fax

Practice location:
  • Phone: 808-832-5688
  • Fax: 808-832-5698
Mailing address:
  • Phone: 808-832-5688
  • Fax: 808-832-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT-406
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: