Healthcare Provider Details

I. General information

NPI: 1366574980
Provider Name (Legal Business Name): TRACY LYNN GEREAU MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W HAWTHORNE ST
FALLBROOK CA
92028-2053
US

IV. Provider business mailing address

3762 VIA DEL RANCHO
OCEANSIDE CA
92056-7208
US

V. Phone/Fax

Practice location:
  • Phone: 760-731-3235
  • Fax: 760-731-4950
Mailing address:
  • Phone: 760-450-4931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF38751
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: