Provider Demographics
NPI:1760736953
Name:DELIMAN, TRACY LYNNE (PHD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNNE
Last Name:DELIMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:LYNNE
Other - Last Name:HIGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11245 RAGAN WAY
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95949-6753
Mailing Address - Country:US
Mailing Address - Phone:510-725-5454
Mailing Address - Fax:
Practice Address - Street 1:11245 RAGAN WAY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95949-6753
Practice Address - Country:US
Practice Address - Phone:510-725-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17424103T00000X
CA17424103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY17424OtherPSYCHOLOGIST LICENSE