Healthcare Provider Details

I. General information

NPI: 1962534594
Provider Name (Legal Business Name): TRACY ANN HOLCOMB BRACKIN MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 SERRANIA AVE
WOODLAND HILLS CA
91364-3301
US

IV. Provider business mailing address

9217 SOPHIA AVE
NORTH HILLS CA
91343-3811
US

V. Phone/Fax

Practice location:
  • Phone: 818-657-3143
  • Fax: 818-347-0184
Mailing address:
  • Phone: 818-891-4361
  • Fax: 818-347-0184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number62576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: