Provider Demographics
NPI:1306980859
Name:YAN, TRACEY Y
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:Y
Last Name:YAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:YEUNHUEY
Other - Middle Name:
Other - Last Name:YAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 7402
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94537-7402
Mailing Address - Country:US
Mailing Address - Phone:510-490-9600
Mailing Address - Fax:
Practice Address - Street 1:39833 PASEO PADRE PKWY STE E
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2980
Practice Address - Country:US
Practice Address - Phone:510-490-9600
Practice Address - Fax:510-490-9601
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC43261106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01674804Medicaid