Provider Demographics
NPI:1417463605
Name:ENDELSON, TRACIE ALEXANDRA (LAC)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:ALEXANDRA
Last Name:ENDELSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-4322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-4322
Practice Address - Country:US
Practice Address - Phone:424-265-2480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-25
Last Update Date:2017-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17874171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist