Provider Demographics
NPI:1083058903
Name:CORREIA, TRACI L
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:CORREIA
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 1:5634 JEREMY WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-2867
Mailing Address - Country:US
Mailing Address - Phone:209-888-4969
Mailing Address - Fax:
Practice Address - Street 1:5634 JEREMY WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95212-2867
Practice Address - Country:US
Practice Address - Phone:209-888-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator