Provider Demographics
NPI:1073041935
Name:TRACY, KRISTIN NICOLE (LISW-SUPV)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:NICOLE
Last Name:TRACY
Suffix:
Gender:F
Credentials:LISW-SUPV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8224 MENTOR AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-5743
Mailing Address - Country:US
Mailing Address - Phone:440-392-2222
Mailing Address - Fax:
Practice Address - Street 1:8224 MENTOR AVE STE 208
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5743
Practice Address - Country:US
Practice Address - Phone:440-392-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI1440505-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical