Provider Demographics
NPI:1619797412
Name:REISCH, TRACEY (PT, DPT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:REISCH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5473 KEARNY VILLA RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1160
Mailing Address - Country:US
Mailing Address - Phone:858-565-6910
Mailing Address - Fax:858-565-6911
Practice Address - Street 1:5473 KEARNY VILLA RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1160
Practice Address - Country:US
Practice Address - Phone:858-565-6910
Practice Address - Fax:858-565-6911
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3069832251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics