Provider Demographics
NPI:1730225640
Name:CARLIS, TRACY LYNN (PHD)
Entity type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LYNN
Last Name:CARLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5000 HAYVENHURST AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-1115
Mailing Address - Country:US
Mailing Address - Phone:818-713-0508
Mailing Address - Fax:818-703-8050
Practice Address - Street 1:5000 HAYVENHURST AVE
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1115
Practice Address - Country:US
Practice Address - Phone:818-713-0508
Practice Address - Fax:818-703-8050
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16888170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics