Provider Demographics
NPI:1629495718
Name:GREEN, TRACEY YVETTE
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:YVETTE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:GREEN
Other - Last Name:WEATHERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8730 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-2412
Mailing Address - Country:US
Mailing Address - Phone:323-751-3026
Mailing Address - Fax:
Practice Address - Street 1:5190 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-6510
Practice Address - Country:US
Practice Address - Phone:562-428-4111
Practice Address - Fax:562-984-5610
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator