Provider Demographics
NPI:1992137400
Name:CASILLAS, TRACEY
Entity type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:
Last Name:CASILLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 KINGS COUNTY DR STE 104
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-5785
Mailing Address - Country:US
Mailing Address - Phone:559-000-0000
Mailing Address - Fax:
Practice Address - Street 1:1222 W LACEY BLVD
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5901
Practice Address - Country:US
Practice Address - Phone:559-235-9239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA135909106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist