Provider Demographics
NPI:1407459639
Name:AMERSON, TRACIE
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:AMERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:
Other - Last Name:SPANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2351 CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-3743
Mailing Address - Country:US
Mailing Address - Phone:858-573-2227
Mailing Address - Fax:858-496-2113
Practice Address - Street 1:2351 CARDINAL LN
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-3743
Practice Address - Country:US
Practice Address - Phone:858-573-2227
Practice Address - Fax:858-496-2113
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician