Provider Demographics
NPI:1467007815
Name:SMALL, TRACEY (MFT INTERN)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:MFT INTERN
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 4322
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86302-4322
Mailing Address - Country:US
Mailing Address - Phone:928-710-6860
Mailing Address - Fax:
Practice Address - Street 1:2517 N GREAT WESTERN DR STE L
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2597
Practice Address - Country:US
Practice Address - Phone:623-688-8201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist