Provider Demographics
NPI:1386171650
Name:MANIGAULT, TRACEY DENISE (MA, CSP)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:DENISE
Last Name:MANIGAULT
Suffix:
Gender:F
Credentials:MA, CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9224 N 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-3504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8900 N CENTRAL AVE STE 108F
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2869
Practice Address - Country:US
Practice Address - Phone:928-206-1766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4241632101YS0200X, 103TS0200X
106S00000X, 171400000X, 171M00000X, 251S00000X, 373H00000X, 374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No374700000XNursing Service Related ProvidersTechnician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4241632OtherCERTIFIED SCHOOL PSYCHOLOGIST