Provider Demographics
NPI:1699786681
Name:DEJARNETTE-HOLLY, TRACIE MICHELE (MD)
Entity type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:MICHELE
Last Name:DEJARNETTE-HOLLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1607 WOOD SONG DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-6492
Mailing Address - Country:US
Mailing Address - Phone:281-804-2531
Mailing Address - Fax:
Practice Address - Street 1:22001 SOUTHWEST FWY STE 125
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-7002
Practice Address - Country:US
Practice Address - Phone:832-219-3898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK95162084F0202X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX029799603Medicaid
TXG23405Medicare UPIN
TX029799603Medicaid
TX8549M2Medicare PIN