Provider Demographics
NPI:1679754972
Name:SMITH, TRACY A
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:A
Last Name:SMITH
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 1:5655 LINDERO CANYON RD STE 726
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91362-4068
Mailing Address - Country:US
Mailing Address - Phone:818-259-7650
Mailing Address - Fax:
Practice Address - Street 1:5655 LINDERO CANYON RD STE 726
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91362
Practice Address - Country:US
Practice Address - Phone:818-259-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2018-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82987106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist