Provider Demographics
NPI:1023381886
Name:WILBORN, TRACY LAVERIA (CERTIFICATE)
Entity Type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:LAVERIA
Last Name:WILBORN
Suffix:
Gender:F
Credentials:CERTIFICATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1874 BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3457
Mailing Address - Country:US
Mailing Address - Phone:909-386-0523
Mailing Address - Fax:909-386-0529
Practice Address - Street 1:1874 SO. BUSINESS CENTER DRIVE
Practice Address - Street 2:SAME AS BUSINESS MAILING ADDRESS
Practice Address - City:SAN BERNADINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:909-386-0523
Practice Address - Fax:909-386-0529
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)