Provider Demographics
NPI:1972785830
Name:TARIS, TRACY THERESA (MFT INTERN)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:THERESA
Last Name:TARIS
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25136 MARCI WAY
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-3051
Mailing Address - Country:US
Mailing Address - Phone:818-618-2061
Mailing Address - Fax:818-618-2061
Practice Address - Street 1:23822 VALENCIA BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-5302
Practice Address - Country:US
Practice Address - Phone:818-618-2061
Practice Address - Fax:818-618-2061
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 50782106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist