Provider Demographics
NPI:1407100100
Name:TAGACA, TRACY (MA, MED)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:TAGACA
Suffix:
Gender:F
Credentials:MA, MED
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 6465
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-6465
Mailing Address - Country:US
Mailing Address - Phone:808-756-5696
Mailing Address - Fax:
Practice Address - Street 1:67-1232 KOALIULA PL
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8461
Practice Address - Country:US
Practice Address - Phone:808-756-5696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health