Provider Demographics
NPI:1043435944
Name:TRACY, HATTIE M (LISW, LCDCIII)
Entity Type:Individual
Prefix:
First Name:HATTIE
Middle Name:M
Last Name:TRACY
Suffix:
Gender:F
Credentials:LISW, LCDCIII
Other - Prefix:
Other - First Name:HATTIE
Other - Middle Name:M
Other - Last Name:TRACY-KRAMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW,LCDCIII
Mailing Address - Street 1:4209 STATE ROUTE 44
Mailing Address - Street 2:
Mailing Address - City:ROOTSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44272-9698
Mailing Address - Country:US
Mailing Address - Phone:330-325-6697
Mailing Address - Fax:330-325-5970
Practice Address - Street 1:4209 STATE ROUTE 44
Practice Address - Street 2:
Practice Address - City:ROOTSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44272-9698
Practice Address - Country:US
Practice Address - Phone:330-325-6697
Practice Address - Fax:330-325-5970
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0900274104100000X
OH081003101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)