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General NPI Number Information
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NPI Number | 1720595119
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Entity Type | Individual
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Provider Name | LISA COUSINS TRACY PHD, MSW, LCSW
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Gender | Female
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Dates
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Enumeration Date | 01/07/2018
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Last Update Date | 01/07/2018
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Provider Practice Location Address
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Address Line | 3120 TELEGRAPH AVE STE 10
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City | BERKELEY
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State | CA
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Zip | 94705-1965
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Country | US
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Telephone | 510-463-1797
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Fax |
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Provider Business Mailing Address
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Address Line | 4706 MANILA AVE
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City | OAKLAND
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State | CA
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Zip | 94609-2272
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Country | US
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Telephone | 510-882-4896
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 64812
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License Number State | CA
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