Provider Demographics
NPI:1003120205
Name:TEMPLE, TRACIE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:TEMPLE
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 1:411 W SEASIDE WAY UNIT 1403
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-7988
Mailing Address - Country:US
Mailing Address - Phone:562-595-3099
Mailing Address - Fax:
Practice Address - Street 1:411 W SEASIDE WAY UNIT 1403
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-7988
Practice Address - Country:US
Practice Address - Phone:562-595-3099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic