Provider Demographics
NPI:1538924766
Name:GRIFFIN, TRACEY J (EDD, NCSP)
Entity type:Individual
Prefix:DR
First Name:TRACEY
Middle Name:J
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:EDD, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 RAINBOW DR # 16224
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77399-2062
Mailing Address - Country:US
Mailing Address - Phone:850-420-0404
Mailing Address - Fax:
Practice Address - Street 1:116 MAURICE AVE NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4213
Practice Address - Country:US
Practice Address - Phone:229-237-2960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1800103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool