Provider Demographics
NPI:1831234277
Name:MASTANDREA, TRACI CRITTON (PHD)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:CRITTON
Last Name:MASTANDREA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 AVENUE I STE 19
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5619
Mailing Address - Country:US
Mailing Address - Phone:310-980-7162
Mailing Address - Fax:
Practice Address - Street 1:205 AVENUE I STE 19
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5619
Practice Address - Country:US
Practice Address - Phone:310-980-7162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent