Provider Demographics
NPI:1174040679
Name:HALLUM, TRACINE RENEE (LEP)
Entity Type:Individual
Prefix:MS
First Name:TRACINE
Middle Name:RENEE
Last Name:HALLUM
Suffix:
Gender:F
Credentials:LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 HILTON HEAD WAY UNIT 27
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-4223
Mailing Address - Country:US
Mailing Address - Phone:661-873-5110
Mailing Address - Fax:
Practice Address - Street 1:401 19TH ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-4907
Practice Address - Country:US
Practice Address - Phone:661-873-5110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3148103K00000X, 103TB0200X, 103TM1800X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities