=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770002875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACIE PRIETO CATC-III
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2017
-----------------------------------------------------
Last Update Date | 09/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 823 GATEWAY CENTER WAY
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-515-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2047 30TH ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-794-8830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 177048-III
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------