Provider Demographics
NPI:1881434173
Name:PAINE, TRACIE LEIGH (REGISTERED SUD COUNS)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:LEIGH
Last Name:PAINE
Suffix:
Gender:F
Credentials:REGISTERED SUD COUNS
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:LEIGH
Other - Last Name:RICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:815 LISBON AVE UPPR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-1445
Mailing Address - Country:US
Mailing Address - Phone:510-631-3049
Mailing Address - Fax:
Practice Address - Street 1:6330 THORNTON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-3734
Practice Address - Country:US
Practice Address - Phone:510-792-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-25
Last Update Date:2024-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)