MEDICARE: TRACIE TEMPLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TF0200X	Forensic Psychologist

General Provider Information

NPI Number	:	1003120205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACIE TEMPLE

Provider Business Mailing Address
First Line	:	411 W SEASIDE WAY UNIT 1403
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-7988
Country	:	US
Telephone Number	:	562-595-3099
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 W SEASIDE WAY UNIT 1403
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90802-7988
Country	:	US
Telephone Number	:	562-595-3099
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2010
Last Update Date	:	07/29/2010

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Directions to “ TRACIE TEMPLE ” Practice Location

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