Provider Demographics
NPI:1326899303
Name:MATHEWS, TRACY LYNN
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:MATHEWS
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:PO BOX 472
Mailing Address - Street 2:
Mailing Address - City:BLUE LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95525-0472
Mailing Address - Country:US
Mailing Address - Phone:707-834-6324
Mailing Address - Fax:
Practice Address - Street 1:2355 CENTRAL AVE STE D
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-3684
Practice Address - Country:US
Practice Address - Phone:707-672-5527
Practice Address - Fax:707-633-1755
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician