Provider Demographics
NPI:1255805172
Name:SINGH, TRACIE NICKOLE (MFTI)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:NICKOLE
Last Name:SINGH
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9176 PROSPERITY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-8466
Mailing Address - Country:US
Mailing Address - Phone:904-274-1630
Mailing Address - Fax:
Practice Address - Street 1:1125 W BEAVER STREET
Practice Address - Street 2:SUITE 205
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204
Practice Address - Country:US
Practice Address - Phone:904-712-3540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3037106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty