Basic Information
| Provider Information | |||||||||
| NPI: | 1205142866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALE | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 KINGSWAY DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462051521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174661000 | ||||||||
| FaxNumber: | 3174662000 | ||||||||
| Practice Location | |||||||||
| Address1: | 4740 KINGSWAY DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462051521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174661000 | ||||||||
| FaxNumber: | 3174662000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2010 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 20042484A | IN | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 201009820 | 05 | IN | MEDICAID |