Provider Demographics
NPI:1184925331
Name:HERMAN BROOME, TRACEY LINDA (LMFT)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LINDA
Last Name:HERMAN BROOME
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 ALLYN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2256
Mailing Address - Country:US
Mailing Address - Phone:415-460-5222
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT VINCENTS DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1504
Practice Address - Country:US
Practice Address - Phone:415-507-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 40928106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist