Provider Demographics
NPI:1750406500
Name:PRINTUP-KHAN, TRACI ROCHELLE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:ROCHELLE
Last Name:PRINTUP-KHAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W THOUSAND OAKS BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-4462
Mailing Address - Country:US
Mailing Address - Phone:805-777-3516
Mailing Address - Fax:
Practice Address - Street 1:125 W THOUSAND OAKS BLVD STE 500
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-4462
Practice Address - Country:US
Practice Address - Phone:805-777-3516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS167061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical