Provider Demographics
NPI:1790555878
Name:HEWITT, TRACIE (MA, LEP #4031)
Entity Type:Individual
Prefix:
First Name:TRACIE
Middle Name:
Last Name:HEWITT
Suffix:
Gender:F
Credentials:MA, LEP #4031
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4811 CHIPPENDALE DR STE 501
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95841-2553
Mailing Address - Country:US
Mailing Address - Phone:916-834-8096
Mailing Address - Fax:
Practice Address - Street 1:4811 CHIPPENDALE DR STE 501
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-2553
Practice Address - Country:US
Practice Address - Phone:916-834-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4031103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool