=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982948725
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY SUSAN KELLY M.A. MFT INTERN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2012
-----------------------------------------------------
Last Update Date | 11/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 S ARLINGTON AVE STE 212-D
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89509-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-742-7764
-----------------------------------------------------
Fax | 775-622-4509
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 50237
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89435-0237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-742-7764
-----------------------------------------------------
Fax | 775-622-4509
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------