Provider Demographics
NPI:1740821263
Name:COVEY BORCHARD, TRACIE LOUISE (LMFT)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:LOUISE
Last Name:COVEY BORCHARD
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E AVENIDA RAMONA APT A
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3208
Mailing Address - Country:US
Mailing Address - Phone:949-291-8742
Mailing Address - Fax:
Practice Address - Street 1:800 S EL CAMINO REAL STE 205
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4274
Practice Address - Country:US
Practice Address - Phone:949-291-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-06
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115021106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty