Provider Demographics
NPI:1952076507
Name:WYATT-COLTON, TRACY LEE
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEE
Last Name:WYATT-COLTON
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 1:3055 NW 126TH AVE APT 222
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-6332
Mailing Address - Country:US
Mailing Address - Phone:954-410-6265
Mailing Address - Fax:
Practice Address - Street 1:300 S PINE ISLAND RD STE 253
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2631
Practice Address - Country:US
Practice Address - Phone:305-936-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-14
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical