Provider Demographics
NPI:1598268856
Name:LARUE, TRACY LISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LISA
Last Name:LARUE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:LISA
Other - Last Name:LARUE YALOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1801 BUSH ST STE 209
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-5297
Mailing Address - Country:US
Mailing Address - Phone:415-206-1990
Mailing Address - Fax:
Practice Address - Street 1:1801 BUSH ST STE 209
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-5297
Practice Address - Country:US
Practice Address - Phone:415-206-1990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19398103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical