Provider Demographics
NPI:1467291427
Name:AGUOCHA-SAM, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:AGUOCHA-SAM
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 1:6419 GWINNETT LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-5320
Mailing Address - Country:US
Mailing Address - Phone:240-708-2209
Mailing Address - Fax:
Practice Address - Street 1:10770 COLUMBIA PIKE STE 105
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-4402
Practice Address - Country:US
Practice Address - Phone:703-237-2219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician