Provider Demographics
NPI:1235933961
Name:RICHARDSON, TRACY ANN (LAC)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:RICHARDSON
Suffix:
Gender:
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 CRAGMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94708-1330
Mailing Address - Country:US
Mailing Address - Phone:415-233-3691
Mailing Address - Fax:
Practice Address - Street 1:610 CRAGMONT AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94708-1330
Practice Address - Country:US
Practice Address - Phone:415-233-3691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14081261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center