Provider Demographics
NPI:1558918052
Name:OVERLY, TRACY RENE
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:RENE
Last Name:OVERLY
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 1:10 W BAY STATE ST
Mailing Address - Street 2:P.O. BOX 1104
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91802
Mailing Address - Country:US
Mailing Address - Phone:626-656-3431
Mailing Address - Fax:
Practice Address - Street 1:515 COLUMBIA AVE # 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1209
Practice Address - Country:US
Practice Address - Phone:213-249-9388
Practice Address - Fax:213-389-7993
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1076521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical