Healthcare Provider Details

I. General information

NPI: 1124165212
Provider Name (Legal Business Name): TRACY LEFEBVRE ROULET M.A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 W 10TH ST
ANTIOCH CA
94509-1653
US

IV. Provider business mailing address

5523 ALASKA DR
CONCORD CA
94521-4009
US

V. Phone/Fax

Practice location:
  • Phone: 925-777-9540
  • Fax:
Mailing address:
  • Phone: 805-325-1845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: