Provider Demographics
NPI:1003827031
Name:GREGORY, TRACEE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:TRACEE
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1166
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27588-1166
Mailing Address - Country:US
Mailing Address - Phone:919-554-1231
Mailing Address - Fax:919-554-2406
Practice Address - Street 1:833 WAKE FOREST BUSINESS PARK
Practice Address - Street 2:SUITE G
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-7184
Practice Address - Country:US
Practice Address - Phone:919-554-1231
Practice Address - Fax:919-554-2406
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0045531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC135NXOtherBLUE CROSS/ BLUE SHIELD
NC6002724Medicaid