Healthcare Provider Details

I. General information

NPI: 1366004582
Provider Name (Legal Business Name): TRACY LEE GUERRERO-PROCTOR PSYD, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRACY PROCTOR PSYD, LMFT

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2894 MELLOR ST
CORONA CA
92881-3585
US

IV. Provider business mailing address

PO BOX 6659
LAGUNA NIGUEL CA
92607-6659
US

V. Phone/Fax

Practice location:
  • Phone: 949-525-2498
  • Fax:
Mailing address:
  • Phone: 949-525-2498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: