Provider Demographics
NPI:1386487569
Name:DAVIS, TRACYE ELIZABETH (S2N6Z3L5)
Entity type:Individual
Prefix:
First Name:TRACYE
Middle Name:ELIZABETH
Last Name:DAVIS
Suffix:
Gender:F
Credentials:S2N6Z3L5
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41299 PASEO PADRE PKWY APT 1
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-4569
Mailing Address - Country:US
Mailing Address - Phone:510-493-1207
Mailing Address - Fax:
Practice Address - Street 1:41299 PASEO PADRE PKWY APT 1
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-4569
Practice Address - Country:US
Practice Address - Phone:510-493-1207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAS2N6Z3L5106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician