Provider Demographics
NPI:1457935348
Name:TRACEY DWYER MARRIAGE AND FAMILY THERAPIST INC.
Entity Type:Organization
Organization Name:TRACEY DWYER MARRIAGE AND FAMILY THERAPIST INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:DWYER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:354-800-9192
Mailing Address - Street 1:PO BOX 980301
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-0301
Mailing Address - Country:US
Mailing Address - Phone:435-800-9192
Mailing Address - Fax:
Practice Address - Street 1:3022 LOWER SADDLEBACK RD
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-4850
Practice Address - Country:US
Practice Address - Phone:800-435-9192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12229368-0142OtherCORPORATE ID