Provider Demographics
NPI:1619107059
Name:THOMAS, GAYLYNN TRACELL (LCSW)
Entity type:Individual
Prefix:
First Name:GAYLYNN
Middle Name:TRACELL
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 E 118TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90059-2518
Mailing Address - Country:US
Mailing Address - Phone:323-249-2950
Mailing Address - Fax:323-249-2970
Practice Address - Street 1:3737 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 550
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3513
Practice Address - Country:US
Practice Address - Phone:310-609-3890
Practice Address - Fax:310-609-0301
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALV99771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954134752OtherMEDI-CAL