Provider Demographics
NPI:1093247215
Name:STOCKHAM, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:STOCKHAM
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 1:1925 W COLLEGE AVE
Mailing Address - Street 2:APT 185
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-3371
Mailing Address - Country:US
Mailing Address - Phone:909-648-4186
Mailing Address - Fax:
Practice Address - Street 1:1925 W COLLEGE AVE
Practice Address - Street 2:APT 185
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-3371
Practice Address - Country:US
Practice Address - Phone:909-648-4186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)