Healthcare Provider Details

I. General information

NPI: 1790555878
Provider Name (Legal Business Name): TRACIE HEWITT MA, LEP #4031
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 10/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 CHIPPENDALE DR STE 501
SACRAMENTO CA
95841-2553
US

IV. Provider business mailing address

4811 CHIPPENDALE DR STE 501
SACRAMENTO CA
95841-2553
US

V. Phone/Fax

Practice location:
  • Phone: 916-834-8096
  • Fax:
Mailing address:
  • Phone: 916-834-8096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: