MEDICARE: TRACEY G. HENLEY PSY D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PY6020	FL

General Provider Information

NPI Number	:	1528129038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEY G. HENLEY PSY D

Provider Business Mailing Address
First Line	:	4720 CLEVELAND HEIGHTS BLVD STE 105
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-2244
Country	:	US
Telephone Number	:	863-701-9202
Fax Number	:	863-701-9292

Provider Business Practice Location Address
First Line	:	4720 CLEVELAND HEIGHTS BLVD STE 105
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-2244
Country	:	US
Telephone Number	:	863-701-9202
Fax Number	:	863-701-9292

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	06/05/2008

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