=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871779348
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY FABRICK GOTTBETTER M.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2008
-----------------------------------------------------
Last Update Date | 01/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28310 ROADSIDE DR STE 138
-----------------------------------------------------
City | AGOURA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91301-4960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-623-7233
-----------------------------------------------------
Fax | 818-999-1036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28310 ROADSIDE DR STE 138
-----------------------------------------------------
City | AGOURA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91301-4960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-623-7233
-----------------------------------------------------
Fax | 818-999-1036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC50986
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------