Provider Demographics
NPI:1992273734
Name:ELLIS, TRACY (PSYD)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 N MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6115
Mailing Address - Country:US
Mailing Address - Phone:801-298-5222
Mailing Address - Fax:801-294-0295
Practice Address - Street 1:70 N MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6115
Practice Address - Country:US
Practice Address - Phone:801-298-5222
Practice Address - Fax:801-294-0295
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10949998-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty