Provider Demographics
NPI:1871779348
Name:GOTTBETTER, TRACY FABRICK (MA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:FABRICK
Last Name:GOTTBETTER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28310 ROADSIDE DR STE 138
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-4960
Mailing Address - Country:US
Mailing Address - Phone:818-623-7233
Mailing Address - Fax:818-999-1036
Practice Address - Street 1:28310 ROADSIDE DR STE 138
Practice Address - Street 2:
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4960
Practice Address - Country:US
Practice Address - Phone:818-623-7233
Practice Address - Fax:818-999-1036
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC50986106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist