Provider Demographics
NPI:1679873806
Name:CANDIOTTI, TRACY (MS OTR/L)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:CANDIOTTI
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 SANTA FE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-8037
Mailing Address - Country:US
Mailing Address - Phone:707-495-0395
Mailing Address - Fax:
Practice Address - Street 1:2999 CLEVELAND AVE STE D
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2761
Practice Address - Country:US
Practice Address - Phone:707-546-9160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 11198225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist