Provider Demographics
NPI:1528447802
Name:PHANCO, TRACEE (LMFT)
Entity type:Individual
Prefix:
First Name:TRACEE
Middle Name:
Last Name:PHANCO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 CLOVIS AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-1115
Mailing Address - Country:US
Mailing Address - Phone:559-797-1711
Mailing Address - Fax:559-324-6565
Practice Address - Street 1:264 CLOVIS AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-1115
Practice Address - Country:US
Practice Address - Phone:559-797-1711
Practice Address - Fax:559-324-6565
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86023106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist