Provider Demographics
NPI:1699290668
Name:WUTHRICH, TRACIE L (PTA)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:L
Last Name:WUTHRICH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:BRODHEAD
Mailing Address - State:WI
Mailing Address - Zip Code:53520
Mailing Address - Country:US
Mailing Address - Phone:608-558-8818
Mailing Address - Fax:
Practice Address - Street 1:2620 WAUNONA WAY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53713
Practice Address - Country:US
Practice Address - Phone:608-223-1452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2543-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant