Provider Demographics
NPI:1194845214
Name:LOUM, TRACY L
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:LOUM
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 1:825 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3106
Mailing Address - Country:US
Mailing Address - Phone:650-877-8795
Mailing Address - Fax:650-583-0179
Practice Address - Street 1:825 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-3106
Practice Address - Country:US
Practice Address - Phone:650-877-8795
Practice Address - Fax:650-583-0179
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC34539106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist