Provider Demographics
NPI:1669919338
Name:SLACK, TRACY (MFTINTERN)
Entity type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:SLACK
Suffix:
Gender:F
Credentials:MFTINTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-0523
Mailing Address - Country:US
Mailing Address - Phone:559-817-7934
Mailing Address - Fax:
Practice Address - Street 1:1220 W CENTER AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-5911
Practice Address - Country:US
Practice Address - Phone:559-280-5756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF83896106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist