Provider Demographics
NPI:1902294804
Name:ELLISON TAYLOR, TRACEY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:
Last Name:ELLISON TAYLOR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15439 PLANTATION OAKS DR APT 2
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2133
Mailing Address - Country:US
Mailing Address - Phone:813-943-2160
Mailing Address - Fax:
Practice Address - Street 1:15439 PLANTATION OAKS DR APT 2
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2133
Practice Address - Country:US
Practice Address - Phone:813-943-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-30
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical