Provider Demographics
NPI:1215424114
Name:WARSTLER, TRACIE
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:WARSTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 POLK ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1743
Mailing Address - Country:US
Mailing Address - Phone:760-831-4757
Mailing Address - Fax:
Practice Address - Street 1:4111 POLK ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1743
Practice Address - Country:US
Practice Address - Phone:760-831-4757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician