Provider Demographics
NPI:1902183452
Name:NOWELL, TRACEY W (MFT)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:W
Last Name:NOWELL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3190 S BASCOM AVE STE 180
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-2568
Mailing Address - Country:US
Mailing Address - Phone:408-221-3055
Mailing Address - Fax:
Practice Address - Street 1:3190 S BASCOM AVE STE 180
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-2568
Practice Address - Country:US
Practice Address - Phone:408-221-3055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39493106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist