Provider Demographics
NPI:1942328828
Name:MEDEIROS, TRACI JEAN (BA)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:JEAN
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 LINE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-3202
Mailing Address - Country:US
Mailing Address - Phone:508-269-0505
Mailing Address - Fax:
Practice Address - Street 1:14 FORDHAM RD
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-3006
Practice Address - Country:US
Practice Address - Phone:617-782-6460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor