Healthcare Provider Details

I. General information

NPI: 1760407191
Provider Name (Legal Business Name): MARY LYNN TRACY-HEUSNER BA, MA, PHD, MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 D ST SUITE J
DAVIS CA
95616-4695
US

IV. Provider business mailing address

133 D ST SUITE J
DAVIS CA
95616-4695
US

V. Phone/Fax

Practice location:
  • Phone: 530-758-4113
  • Fax: 530-758-4113
Mailing address:
  • Phone: 530-758-4113
  • Fax: 530-758-4113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMFC25900
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: