Provider Demographics
NPI:1043268550
Name:BANE, TRACY L (LCSW)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:L
Last Name:BANE
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 1:3201 SHAMROCK ST S STE 103
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-3349
Mailing Address - Country:US
Mailing Address - Phone:850-894-0061
Mailing Address - Fax:850-894-0062
Practice Address - Street 1:3201 SHAMROCK ST S STE 103
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-3349
Practice Address - Country:US
Practice Address - Phone:850-894-0061
Practice Address - Fax:850-894-0062
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW69531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ057AOtherBLUE SHIELD NUMBER
FLZ057AMedicare ID - Type Unspecified