Provider Demographics
NPI:1659839660
Name:TANENBAUM, TRACEY (LMFT)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:
Last Name:TANENBAUM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3081
Mailing Address - Country:US
Mailing Address - Phone:215-382-6680
Mailing Address - Fax:
Practice Address - Street 1:1800 JFK BLVD STE 888
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-7406
Practice Address - Country:US
Practice Address - Phone:215-382-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF001050106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist