Provider Demographics
NPI:1053507020
Name:WAITE, TRACEY NICOLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:NICOLE
Last Name:WAITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:WAITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1355 S INTERNATIONAL PKWY
Mailing Address - Street 2:STE 1481
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-1694
Mailing Address - Country:US
Mailing Address - Phone:407-559-7011
Mailing Address - Fax:407-559-5443
Practice Address - Street 1:725 N 12TH AVE BLDG B
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-8752
Practice Address - Country:US
Practice Address - Phone:863-494-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 81621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW 8162OtherLCSW
VA0904010054OtherLICENSE