Provider Demographics
NPI:1124455316
Name:TRACY, MICHELLE (LMFT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:TRACY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 S AUBURN ST STE B
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-7576
Mailing Address - Country:US
Mailing Address - Phone:530-277-3998
Mailing Address - Fax:
Practice Address - Street 1:18262 SLIDE MINE RD
Practice Address - Street 2:
Practice Address - City:NORTH SAN JUAN
Practice Address - State:CA
Practice Address - Zip Code:95960
Practice Address - Country:US
Practice Address - Phone:530-277-3998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82311106H00000X
CA106343106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist