Provider Demographics
NPI:1326169053
Name:TEVYAW, TRACY O'LEARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:O'LEARY
Last Name:TEVYAW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 CHALKSTONE AVE # 116B
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4799
Mailing Address - Country:US
Mailing Address - Phone:401-273-7100
Mailing Address - Fax:
Practice Address - Street 1:830 CHALKSTONE AVE # 116B
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4799
Practice Address - Country:US
Practice Address - Phone:401-273-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00755103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical