Provider Demographics
NPI:1518479633
Name:PIMENTEL, TRACEY LEE (MA, LAADC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:LEE
Last Name:PIMENTEL
Suffix:
Gender:F
Credentials:MA, LAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 W CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-4206
Mailing Address - Country:US
Mailing Address - Phone:559-264-7521
Mailing Address - Fax:
Practice Address - Street 1:2550 W CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-4206
Practice Address - Country:US
Practice Address - Phone:559-264-7521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALR10081221101YA0400X
CAR1283161117101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALR10081221OtherCCAPP