MEDICARE: MRS. TRACY LIN WONDERO OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	5201004210	MI

General Provider Information

NPI Number	:	1093292773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACY LIN WONDERO OTR/L

Provider Business Mailing Address
First Line	:	7263 GREEN VALLEY DR
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-8142
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	G1069 N BALLENGER HWY
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48504-4431
Country	:	US
Telephone Number	:	810-235-6676
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2018
Last Update Date	:	07/25/2018

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