MEDICARE: TRACY LYNN ELLIOTT LMFT

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	106H00000X	Marriage & Family Therapist	LMFT-16163	AZ

General Provider Information

NPI Number	:	1770170201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY LYNN ELLIOTT LMFT

Provider Business Mailing Address
First Line	:	17250 N 43RD AVE STE 4
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-4032
Country	:	US
Telephone Number	:	928-362-2716
Fax Number	:

Provider Business Practice Location Address
First Line	:	17250 N 43RD AVE STE 4
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-4032
Country	:	US
Telephone Number	:	928-362-2716
Fax Number	:

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

Provider Enumeration Date	:	12/30/2020
Last Update Date	:	07/23/2024

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