Provider Demographics
NPI:1861896995
Name:BECKER, TRACI LYNNE (CMT)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:LYNNE
Last Name:BECKER
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 BUCK AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-3642
Mailing Address - Country:US
Mailing Address - Phone:707-592-0416
Mailing Address - Fax:
Practice Address - Street 1:595 BUCK AVE
Practice Address - Street 2:SUITE D
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3642
Practice Address - Country:US
Practice Address - Phone:707-592-0416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22101225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist