Provider Demographics
NPI:1215339890
Name:CHOVANEC, TRACY (PSYD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:CHOVANEC
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8253 WHITE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7671
Mailing Address - Country:US
Mailing Address - Phone:909-285-4725
Mailing Address - Fax:909-987-0993
Practice Address - Street 1:8253 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7671
Practice Address - Country:US
Practice Address - Phone:909-285-4725
Practice Address - Fax:909-987-0993
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26690103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY26690OtherPSYCHOLOGIST LICENSE