Provider Demographics
NPI:1073019600
Name:TRACY, KONNI (QMHS)
Entity Type:Individual
Prefix:
First Name:KONNI
Middle Name:
Last Name:TRACY
Suffix:
Gender:F
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5267
Mailing Address - Country:US
Mailing Address - Phone:419-330-5122
Mailing Address - Fax:
Practice Address - Street 1:206 PERRY ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2118
Practice Address - Country:US
Practice Address - Phone:419-782-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health