Provider Demographics
NPI:1043545932
Name:TRACY, BOBBIE LYNN (LADAC)
Entity Type:Individual
Prefix:MRS
First Name:BOBBIE
Middle Name:LYNN
Last Name:TRACY
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SOUTHWEST HIGHLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:CROWNPOINT
Mailing Address - State:NM
Mailing Address - Zip Code:87313
Mailing Address - Country:US
Mailing Address - Phone:505-786-2111
Mailing Address - Fax:505-786-2020
Practice Address - Street 1:SOUTHWEST HIGHLAND DRIVE
Practice Address - Street 2:
Practice Address - City:CROWNPOINT
Practice Address - State:NM
Practice Address - Zip Code:87313
Practice Address - Country:US
Practice Address - Phone:505-786-2111
Practice Address - Fax:505-786-2020
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0120661101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)