Provider Demographics
NPI:1871797183
Name:GREENE MINTZ, TRACY LYNN (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:LYNN
Last Name:GREENE MINTZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 N PACIFIC COAST HWY
Mailing Address - Street 2:#413
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2870
Mailing Address - Country:US
Mailing Address - Phone:310-386-5576
Mailing Address - Fax:310-379-8086
Practice Address - Street 1:409 N PACIFIC COAST HWY
Practice Address - Street 2:#413
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2870
Practice Address - Country:US
Practice Address - Phone:310-386-5576
Practice Address - Fax:310-379-8086
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA239641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical