Provider Demographics
NPI:1508144676
Name:CHAN, TRACEY Y
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:Y
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 ALAMEDA DE LAS PULGAS STE 157
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-1222
Mailing Address - Country:US
Mailing Address - Phone:650-573-2331
Mailing Address - Fax:
Practice Address - Street 1:2000 ALAMEDA DE LAS PULGAS
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1269
Practice Address - Country:US
Practice Address - Phone:650-372-8516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-23
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98255106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist