Basic Information
Provider Information | |||||||||
NPI: | 1174566954 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CECCHINI | ||||||||
FirstName: | TRACY | ||||||||
MiddleName: | BLACK | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | PH.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BLACK-CECCHINI | ||||||||
OtherFirstName: | TRACY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PH.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 9227 STONE VIEW CV | ||||||||
Address2: |   | ||||||||
City: | SANDY | ||||||||
State: | UT | ||||||||
PostalCode: | 840933204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019832708 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | VA SLC HEALTHCARE SYSTEM | ||||||||
Address2: | 500 FOOTHILL DR. | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841480001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015821565 | ||||||||
FaxNumber: | 8015845680 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 5848945-2501 | UT | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 013988-1 | NY | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.