Healthcare Provider Details

I. General information

NPI: 1669919338
Provider Name (Legal Business Name): TRACY SLACK MFTINTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 W CENTER AVE
VISALIA CA
93291-5911
US

IV. Provider business mailing address

PO BOX 523
LEMOORE CA
93245-0523
US

V. Phone/Fax

Practice location:
  • Phone: 559-280-5756
  • Fax:
Mailing address:
  • Phone: 559-817-7934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF83896
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: