Provider Demographics
NPI:1508460213
Name:LEGOHN-HARRIS, TRACI RUTH
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:RUTH
Last Name:LEGOHN-HARRIS
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 1:1858 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-1823
Mailing Address - Country:US
Mailing Address - Phone:323-342-3194
Mailing Address - Fax:
Practice Address - Street 1:1858 W 69TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-1823
Practice Address - Country:US
Practice Address - Phone:323-342-3194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker