Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103K00000X | Behavior Analyst |
NPI | 1003437765 |
---|---|
Provider Name | Tracie Heacox |
First Address | Minneapolis, MN 55419-2035 |
Second Address | Eden Prairie, MN 55346-1718 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2020 |
Last Update Date | 04/05/2020 |