Provider Demographics
NPI:1528129038
Name:HENLEY, TRACEY G (PSY D)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:G
Last Name:HENLEY
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 CLEVELAND HEIGHTS BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2244
Mailing Address - Country:US
Mailing Address - Phone:863-701-9202
Mailing Address - Fax:863-701-9292
Practice Address - Street 1:4720 CLEVELAND HEIGHTS BLVD STE 105
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2244
Practice Address - Country:US
Practice Address - Phone:863-701-9202
Practice Address - Fax:863-701-9292
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6020103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54489ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER
FL54489ZMedicare PIN