Provider Demographics
NPI:1538583745
Name:ROCHA PHELON, TRACEY (PHD)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:
Last Name:ROCHA PHELON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:L
Other - Last Name:ROCHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1078 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01524-1396
Mailing Address - Country:US
Mailing Address - Phone:084-701-5055
Mailing Address - Fax:
Practice Address - Street 1:1078 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEICESTER
Practice Address - State:MA
Practice Address - Zip Code:01524-1396
Practice Address - Country:US
Practice Address - Phone:508-470-1505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9803103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1538583745OtherBCBS MA
MA1538583745OtherUNITED BEHAVIORAL HEALTH
MA91215302OtherNETWORK HEALTH/TUFTS PLAN
MA5621509OtherCIGNA
MA1538583745OtherBEACON