Basic Information
| Provider Information | |||||||||
| NPI: | 1417054990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLET | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 8TH AVE W STE 101 | ||||||||
| Address2: | |||||||||
| City: | PALMETTO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342214737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417764008 | ||||||||
| FaxNumber: | 9418454963 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 N 12TH AVE BLDG B | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342668752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634941242 | ||||||||
| FaxNumber: | 8614910466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2006 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MT2077 | FL | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103T00000X | PY7881 | FL | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | Z090E | 01 | FL | BCBS NUMBER | OTHER |