Provider Demographics
NPI:1679450605
Name:GULLAGE, TRACY (ACSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:GULLAGE
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23373 BASSETT ST
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-2402
Mailing Address - Country:US
Mailing Address - Phone:818-635-0352
Mailing Address - Fax:
Practice Address - Street 1:501 MARIN ST STE 225
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4301
Practice Address - Country:US
Practice Address - Phone:818-635-0352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW1081871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty