Healthcare Provider Details

I. General information

NPI: 1720595119
Provider Name (Legal Business Name): LISA COUSINS TRACY PHD, MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2018
Last Update Date: 01/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 TELEGRAPH AVE STE 10
BERKELEY CA
94705-1965
US

IV. Provider business mailing address

4706 MANILA AVE
OAKLAND CA
94609-2272
US

V. Phone/Fax

Practice location:
  • Phone: 510-463-1797
  • Fax:
Mailing address:
  • Phone: 510-882-4896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number64812
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: