Provider Demographics
NPI:1124268826
Name:DAVIS, TRACEY A
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8932 W HAMMOND LN
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-6956
Mailing Address - Country:US
Mailing Address - Phone:623-536-5860
Mailing Address - Fax:
Practice Address - Street 1:8932 W HAMMOND LN
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-6956
Practice Address - Country:US
Practice Address - Phone:623-536-5860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ525702385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child