Provider Demographics
NPI:1659012706
Name:MIQUELON, TRACY CHANGHUA
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:CHANGHUA
Last Name:MIQUELON
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 1:1094 BOLLIN AVE
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-4708
Mailing Address - Country:US
Mailing Address - Phone:805-621-4166
Mailing Address - Fax:
Practice Address - Street 1:3050 SATURN ST STE 102
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-6281
Practice Address - Country:US
Practice Address - Phone:657-444-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician