Basic Information
| Provider Information | |||||||||
| NPI: | 1831242619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALY | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7809 MASSACHUSETTS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346533028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278414200 | ||||||||
| FaxNumber: | 7278161222 | ||||||||
| Practice Location | |||||||||
| Address1: | 8132 KING HELIE BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346531435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278343959 | ||||||||
| FaxNumber: | 7278343969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 04/01/2013 | ||||||||
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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 | 101YM0800X | MH6037 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X | FL | N | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 768392800 | 05 | FL | MEDICAID | 760623100 | 05 | FL | MEDICAID |