Provider Demographics
NPI:1891175592
Name:FORD, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:FORD
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 1:1839 S ELDORADO STREET
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206
Mailing Address - Country:US
Mailing Address - Phone:209-463-0872
Mailing Address - Fax:209-466-4446
Practice Address - Street 1:1839 S EL DORADO STREET
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206
Practice Address - Country:US
Practice Address - Phone:209-463-0870
Practice Address - Fax:209-466-4446
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator