Provider Demographics
NPI:1285834424
Name:WILLIAMSON, TRACY A
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:WILLIAMSON
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 1:5901 VICTORY CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-9747
Mailing Address - Country:US
Mailing Address - Phone:949-201-9147
Mailing Address - Fax:
Practice Address - Street 1:300 SPECTRUM DR.
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618
Practice Address - Country:US
Practice Address - Phone:949-201-9147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18060103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1285834424OtherNPI