1982948725 NPI number — MS. TRACY SUSAN KELLY M.A. MFT INTERN

Table of content: MS. TRACY SUSAN KELLY M.A. MFT INTERN (NPI 1982948725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982948725 NPI number — MS. TRACY SUSAN KELLY M.A. MFT INTERN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
TRACY
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.A. MFT INTERN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982948725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 50237
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARKS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89435-0237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-742-7764
Provider Business Mailing Address Fax Number:
775-622-4509

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 S ARLINGTON AVE STE 212-D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89509-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-742-7764
Provider Business Practice Location Address Fax Number:
775-622-4509
Provider Enumeration Date:
11/17/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)