Provider Demographics
NPI:1447531371
Name:CALLANDRILLO, TRACI EDWARDSON (PHD)
Entity type:Individual
Prefix:DR
First Name:TRACI
Middle Name:EDWARDSON
Last Name:CALLANDRILLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 42ND ST NW
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-4623
Mailing Address - Country:US
Mailing Address - Phone:512-534-8605
Mailing Address - Fax:
Practice Address - Street 1:4545 42ND ST NW
Practice Address - Street 2:SUITE 202
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-4623
Practice Address - Country:US
Practice Address - Phone:512-534-8605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY1000433103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling