Healthcare Provider Details

I. General information

NPI: 1588337281
Provider Name (Legal Business Name): TRACEY R IMSLAND M. ED. AND LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 SANDALWOOD DR
MURPHYS CA
95247-9666
US

IV. Provider business mailing address

PO BOX 806
MURPHYS CA
95247-0806
US

V. Phone/Fax

Practice location:
  • Phone: 949-633-7071
  • Fax:
Mailing address:
  • Phone: 949-633-7071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: