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General NPI Number Information
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NPI Number | 1417054990
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Entity Type | Individual
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Provider Name | TRACY MALLETT PSYD
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Gender | Female
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Dates
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Enumeration Date | 09/19/2006
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Last Update Date | 02/11/2024
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Provider Practice Location Address
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Address Line | 8201 PETERS RD
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City | PLANTATION
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State | FL
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Zip | 33324-3265
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Country | US
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Telephone | 954-665-4115
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Fax |
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Provider Business Mailing Address
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Address Line | 4451 SW 95TH AVE
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City | COOPER CITY
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State | FL
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Zip | 33328-2419
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Country | US
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Telephone | 954-483-1254
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MT2077
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY7881
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License Number State | FL
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