Basic Information
| Provider Information | |||||||||
| NPI: | 1386667905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRACY | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | I. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 909 WALNUT STREET | ||||||||
| Address2: | COB, 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551234 | ||||||||
| FaxNumber: | 2155036792 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 WALNUT STREET | ||||||||
| Address2: | COB, 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191075509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551234 | ||||||||
| FaxNumber: | 2155036792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 09/08/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PS-006545-L | PA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103G00000X | SI 03245 | NJ | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | PS-006545-L | PA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | SI 03245 | NJ | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0017881100002 | 05 | PA | MEDICAID | 8109303 | 05 | NJ | MEDICAID |