Healthcare Provider Details

I. General information

NPI: 1881434173
Provider Name (Legal Business Name): TRACIE LEIGH PAINE REGISTERED SUD COUNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TRACIE LEIGH RICE

II. Dates (important events)

Enumeration Date: 05/25/2024
Last Update Date: 05/25/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 THORNTON AVE
NEWARK CA
94560-3734
US

IV. Provider business mailing address

815 LISBON AVE UPPR
OAKLAND CA
94601-1445
US

V. Phone/Fax

Practice location:
  • Phone: 510-792-4357
  • Fax:
Mailing address:
  • Phone: 510-631-3049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: