Basic Information
| Provider Information | |||||||||
| NPI: | 1013970037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARVEY | ||||||||
| FirstName: | TRACIE | ||||||||
| MiddleName: | DANIELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4174 LEVELSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907124031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5622344750 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 225 ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | SANGER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936572128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598757705 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | G83052 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | G83052 | 05 | CA | MEDICAID | 00G830520 | 05 | CA | MEDICAID |