Basic Information
| Provider Information | |||||||||
| NPI: | 1922207141 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | PATRICIA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2728 DURANT AVENUE | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108419230 | ||||||||
| FaxNumber: | 5108410167 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 ADDISON STREET | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108419230 | ||||||||
| FaxNumber: | 5108410167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 01/16/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.