Provider Demographics
NPI:1033636972
Name:SMITH, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:
Other - Last Name:CANTRELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:TLMFT, LAC
Mailing Address - Street 1:900 N POPLAR ST STE 103
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-1968
Mailing Address - Country:US
Mailing Address - Phone:316-803-1011
Mailing Address - Fax:316-803-1754
Practice Address - Street 1:900 N POPLAR ST STE 103
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-1968
Practice Address - Country:US
Practice Address - Phone:316-803-1011
Practice Address - Fax:316-803-1754
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2885106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist