Provider Demographics
NPI:1659956969
Name:BARRAGAN, TRACY JASMIN
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:JASMIN
Last Name:BARRAGAN
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 1:253 N SAN GABRIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3429
Mailing Address - Country:US
Mailing Address - Phone:818-844-3376
Mailing Address - Fax:818-844-3376
Practice Address - Street 1:253 N SAN GABRIEL BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3429
Practice Address - Country:US
Practice Address - Phone:818-844-3376
Practice Address - Fax:818-844-4203
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-12-15
Deactivation Date:2021-09-28
Deactivation Code:
Reactivation Date:2021-10-26
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician