Provider Demographics
NPI:1710124078
Name:TERRY, TRACI (LPT)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 MIRAMAR WALK
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2216 MIRAMAR WALK
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93035-2628
Practice Address - Country:US
Practice Address - Phone:805-290-9787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT33125167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician