Provider Demographics
NPI:1922112069
Name:TAKETA FUGAZZI, TRACEY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:TAKETA FUGAZZI
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:KOTOMI
Other - Last Name:TAKETA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:7455 W WASHINGTON AVE
Mailing Address - Street 2:#480
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-4337
Mailing Address - Country:US
Mailing Address - Phone:702-889-5525
Mailing Address - Fax:
Practice Address - Street 1:7455 W WASHINGTON AVE
Practice Address - Street 2:#480
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-4337
Practice Address - Country:US
Practice Address - Phone:702-889-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4113-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPENDINGOtherMEDICARE