Provider Demographics
NPI:1023307766
Name:THIEM, TRACY D (PHD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:D
Last Name:THIEM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 4TH ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3043
Mailing Address - Country:US
Mailing Address - Phone:707-637-3022
Mailing Address - Fax:
Practice Address - Street 1:7 4TH ST
Practice Address - Street 2:SUITE 7
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3043
Practice Address - Country:US
Practice Address - Phone:707-637-3022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24037103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical