Provider Demographics
NPI:1710959101
Name:NIX, TRACI D (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:D
Last Name:NIX
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-1902
Mailing Address - Country:US
Mailing Address - Phone:206-579-2305
Mailing Address - Fax:
Practice Address - Street 1:194 FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515
Practice Address - Country:US
Practice Address - Phone:206-579-2305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041928A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200473540AMedicaid
IN200473540AMedicaid