Provider Demographics
NPI:1992050694
Name:SUBLET, TRACY BERNARD
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:BERNARD
Last Name:SUBLET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 M0RESBYST
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-5219
Mailing Address - Country:US
Mailing Address - Phone:817-657-3586
Mailing Address - Fax:
Practice Address - Street 1:5200 IVY WOOD LN
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-4037
Practice Address - Country:US
Practice Address - Phone:817-657-3586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator