Healthcare Provider Details

I. General information

NPI: 1164510426
Provider Name (Legal Business Name): MICHAEL WILLIAM TRAGAKIS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL DRIVE 116B VA SALT LAKE CITY HEALTH CARE SYSTEM
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

3176 S 900 E APT 5
SALT LAKE CITY UT
84106-2157
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 801-520-1050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6272971-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: