Provider Demographics
NPI:1417054990
Name:MALLETT, TRACY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:
Last Name:MALLETT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4451 SW 95TH AVE
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2419
Mailing Address - Country:US
Mailing Address - Phone:954-483-1254
Mailing Address - Fax:
Practice Address - Street 1:8201 PETERS RD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3265
Practice Address - Country:US
Practice Address - Phone:954-665-4115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2024-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2077106H00000X
FLPY7881103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ090EOtherBCBS NUMBER