Provider Demographics
NPI:1639203623
Name:MALBROUGH, TRACY LAVETTE
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:LAVETTE
Last Name:MALBROUGH
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 1:11942 OLD RIVER SCHOOL RD
Mailing Address - Street 2:SUITE #12A
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-2159
Mailing Address - Country:US
Mailing Address - Phone:818-554-3886
Mailing Address - Fax:
Practice Address - Street 1:8019 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-3409
Practice Address - Country:US
Practice Address - Phone:323-586-7333
Practice Address - Fax:323-319-1998
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01605808Medicare UPIN