Provider Demographics
NPI:1437487824
Name:GILLETTE, TRACY M (PHD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:GILLETTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12773 ARBOR LAKES PKWY N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7061
Mailing Address - Country:US
Mailing Address - Phone:612-242-5830
Mailing Address - Fax:
Practice Address - Street 1:1819 CLIFF DR STE F
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93109-1650
Practice Address - Country:US
Practice Address - Phone:612-242-5830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5167103T00000X
CA30853103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist