Provider Demographics
NPI:1174566954
Name:CECCHINI, TRACY BLACK III (PHD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:BLACK
Last Name:CECCHINI
Suffix:III
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:BLACK-CECCHINI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:9227 STONE VIEW CV
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-3204
Mailing Address - Country:US
Mailing Address - Phone:801-983-2708
Mailing Address - Fax:
Practice Address - Street 1:VA SLC HEALTHCARE SYSTEM
Practice Address - Street 2:500 FOOTHILL DR.
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:801-584-5680
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5848945-2501103TC0700X
NY013988-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC7984Medicare ID - Type Unspecified
NYP39060Medicare UPIN