Provider Demographics
NPI:1215709332
Name:PAVLAS, TRACI LEANNE (CRC, NPN)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:LEANNE
Last Name:PAVLAS
Suffix:
Gender:F
Credentials:CRC, NPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 PENNSYLVANIA AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4561
Mailing Address - Country:US
Mailing Address - Phone:619-988-1218
Mailing Address - Fax:
Practice Address - Street 1:1402 PENNSYLVANIA AVE APT 12
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4561
Practice Address - Country:US
Practice Address - Phone:619-988-1218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA148809101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor