Provider Demographics
NPI:1750763108
Name:NIBO, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:NIBO
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 1:900 W TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-4457
Mailing Address - Country:US
Mailing Address - Phone:310-484-4177
Mailing Address - Fax:
Practice Address - Street 1:900 W TEMPLE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-4457
Practice Address - Country:US
Practice Address - Phone:310-484-4177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAACSW 72937101YM0800X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health