Provider Demographics
NPI:1063605343
Name:GOLBACH, TRACI A (PHD)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:A
Last Name:GOLBACH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W TYRONE RD
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6517
Mailing Address - Country:US
Mailing Address - Phone:865-481-6170
Mailing Address - Fax:865-483-6697
Practice Address - Street 1:240 W. TYRONE RD
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830
Practice Address - Country:US
Practice Address - Phone:865-481-6170
Practice Address - Fax:865-483-6697
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2842103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441848Medicaid