Provider Demographics
NPI:1306309588
Name:TRACEY, KERRIE ALYSE-REZA
Entity type:Individual
Prefix:MRS
First Name:KERRIE
Middle Name:ALYSE-REZA
Last Name:TRACEY
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 1:18025 GRAND PROSPERITY DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-4966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1590 BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-6101
Practice Address - Country:US
Practice Address - Phone:703-596-9332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst