Provider Demographics
NPI:1750089462
Name:KUJABI, TRACEY JAKEA (MH, CBT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:JAKEA
Last Name:KUJABI
Suffix:
Gender:F
Credentials:MH, CBT
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:JAKEA
Other - Last Name:BLAKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MH, CBT
Mailing Address - Street 1:9422 E BROADWAY RD APT A305
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-2594
Mailing Address - Country:US
Mailing Address - Phone:480-680-4461
Mailing Address - Fax:
Practice Address - Street 1:9422 E BROADWAY RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85208-2575
Practice Address - Country:US
Practice Address - Phone:480-680-4461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
10662322101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty