Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | LAC-17108 | AZ |
NPI | 1003429937 |
---|---|
Provider Name | Traci Renee Manry |
First Address | Phoenix, AZ 85032-3351 |
Second Address | Phoenix, AZ 85032-3351 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/08/2020 |
Last Update Date | 29/08/2020 |