Provider Demographics
NPI:1396025284
Name:YOUNG, TRACY LEE
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:YOUNG
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 1:1152 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5517
Mailing Address - Country:US
Mailing Address - Phone:707-263-8796
Mailing Address - Fax:707-263-5886
Practice Address - Street 1:1152 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5517
Practice Address - Country:US
Practice Address - Phone:707-263-8796
Practice Address - Fax:707-263-5886
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator