Provider Demographics
NPI:1447473236
Name:HEGGUM, TRACEY LORRAINE
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LORRAINE
Last Name:HEGGUM
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 1:303 WATER ST. SUITE#6
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062
Mailing Address - Country:US
Mailing Address - Phone:831-471-3900
Mailing Address - Fax:831-421-0480
Practice Address - Street 1:303 WATER ST STE 6
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4028
Practice Address - Country:US
Practice Address - Phone:831-471-3900
Practice Address - Fax:831-421-0480
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health